Photodynamic compositions and methods of use

ABSTRACT

The present invention is directed to compositions and methods targeting cells in a subject harboring conditions or at risk for conditions that would benefit from gas-based diagnoses and therapies. The present invention relates to the use of fluorochemical compositions and methods of delivery that result in retention of the fluorochemical composition and any bioactive agent, including gaseous substances, delivered in combination with the fluorochemical composition. The present invention also relates to the use of fluorochemical compositions in conjunction with oxygen and photo sensitizers to enhance photodynamic diagnosis and photodynamic therapy.

FIELD OF THE INVENTION

The present invention generally relates to compositions and methods for the administration of gas-based therapies and/or bioactive agents to a subject in need thereof. In particular, the present invention relates to methods, systems, and compositions comprising fluorochemical composition for use in the delivery of diagnostics and therapies to a target area in a subject that are retained in the target area for a sufficient time to provide a benefit.

BACKGROUND OF THE INVENTION

The use of gas-based therapies has proven useful in accelerating external wound healing and in treating lung conditions and injury. Compositions and methods of exploiting the benefits of gas-based therapies for the treatment of internal ailments has yet to be effectively exploited. Internal ailments that would benefit from gas-based therapies include internal injuries as well as cancer.

Regarding cancer, it has been long known that cancer cells are able to adapt and survive in a variety of microenvironments. For instance, there are some cancer cells that thrive in microenvironments having available oxygen, similar to those of normal cells. Also, there are some cancer cells that thrive in microenvironments lacking oxygen due, in part, to a growth rate that outpaces the establishment of vasculature capable of delivering oxygen. These oxygen deprived cancer cells metabolize glucose by aerobic glycolysis. This phenomenon, known as the Warburg effect, is characterized by increased glycolysis and lactate production regardless of oxygen availability. Aerobic glycolysis is often accompanied by several changes in cell metabolic processes including an increase in glucose and glutamine uptake.

Cancer therapies include targeting these different metabolic processes of cancer cells. However, therapies that alter the availability of oxygen using gas-based therapies in the microenvironment of a cancer cell, or injury site, have yet to be developed. One of the biggest barriers to such gas-based therapies is the delivery and retention of such therapies to an internal target. Fibroblasts and macrophages are cells that are known to associate with cancer referred as stroma and thereby can be used as a surrogate marker of cancer since locating this stroma enables an indirect diagnostic for cancer.

Photodynamic therapy is a subset of gas-based therapy in that light is used to induce the formation of reactive oxygen species in tissues. The formation and maintenance of cell killing levels of reactive oxygen species depends upon the availability of local oxygen. In hypoxic tumors, where oxygen levels are low, additional oxygen may be provided. Cheng and coworkers (Nature Communications 6:8795, 2015) reported the enhanced killing of endogenous CT26 murine colon adenocarcinomas in mice by administering (intravenous as well as intratumoral injection) the near infrared photosensitizer IR780 with the oxygen-bearing perfluorohexane compared to IR780 alone. However, Cheng and coworkers did not demonstrate anti-stromal activity or a durable anti-cancer response.

Near infrared photoimmunotherapy (PIT) is a form of PDT that targets the photosensitizer to the prescribed tissue or cell type. Sato and coworkers (Mol. Cancer Ther. 14(1): 141-150, 2015) demonstrated the reduction of luciferase-based luminescence production by SKOV-3/luc tumors in mice injected with IR700 conjugated with trastuzumab (PIT-treated) compared to IR only (NIR-treated). Both groups were treated with 100 J/cm2 of NIR light at day zero. The PIT-treated mice showed lower relative luminescence units (RLU) compared to NIR-treated mice at day 4 post light treatment, demonstrating some cancer cell reduction in the PIT group. However, by day 14, the RLU of the PIT-treatment group recovered to post-treatment levels.

Accordingly, a need exists for gas-based diagnostics and therapeutics, and the delivery thereof with efficacy and target site retention, and enhanced and long-term PDT killing of tumors. The compositions and methods of the present invention provide such gas-based diagnostics and therapeutics and therapeutic delivery with efficacy and target site retention, and enhanced PDT tumor killing and post-surgical site sterilization.

SUMMARY OF THE INVENTION

In a first aspect, the invention provides a composition useful in the treatment of cancer that contains oxygen, a perfluorocarbon, and a photosensitizer. In one embodiment, the composition is free of carbon dioxide. In one embodiment, the perfluorocarbon is neat or emulsified perflubron. In one embodiment, the photosensitizer is a known photosensitizer for PDT such as talaporfin, verteporfin, hexaminolevulinate, or Photofrin. In another embodiment, the photosensitizer has biological activity, such as nintedanib which has PKI activity. In other embodiments, the photosensitizer is linked to another molecule such as a therapeutic antibody or other molecule having biological effector properties (e.g., a protein tyrosine kinase inhibitor, an anti-angiogenic macromolecule, or the like). In one embodiment, the oxygen is molecular oxygen (i.e., O₂).

In a second aspect, the invention provides a system useful in the treatment of cancer comprising oxygen, a perfluorocarbon, a photosensitizer, and a cap. In one embodiment, the system is free of carbon dioxide. In one embodiment, the perfluorocarbon is neat or emulsified perflubron. In one embodiment, the photosensitizer is a known photosensitizer for PDT such as talaporfin, verteporfin, hexaminolevulinate, or Photofrin. In another embodiment, the photosensitizer has biological activity, such as nintedanib which has PKI activity. In other embodiments, the photosensitizer is linked to another molecule such as a therapeutic antibody or other molecule having biological effector properties (e.g., a protein tyrosine kinase inhibitor, an anti-angiogenic macromolecule, or the like). In one embodiment, the oxygen is molecular oxygen (i.e., O₂). In one embodiment, the cap is positioned at the distal end of an endoscope and the distal end of the cap is open.

In a third aspect, the invention provides a method of treating cancer or killing a tumor by administering to a patient in need thereof a photosensitizer, an oxygenated perfluorocarbon, and light sufficient to stimulate the generation of reactive oxygen species. In one embodiment, the photosensitizer is administered intravenously. In one embodiment, the oxygenated perfluorocarbon is administered per os or topically (e.g., in the case of skin treatment). In one embodiment, the photosensitizer and oxygenated perfluorocarbon are combined and administered to the patient as a combination (PerOxPho). In one embodiment the PerOxPho or the oxygenated perfluorocarbon sans photosensitizer are administered to the tumor through an endoscope. In one embodiment, the distal end of the endoscope is fixed to a cap, the cap is positioned over said tumor, and the PerOxPho or the oxygenated perfluorocarbon sans photosensitizer are delivered into the cap over the tumor. In one embodiment, light, which excites the photosensitizer, is delivered through the endoscope to the tumor.

In one embodiment, the perfluorocarbon is perflubron. In one embodiment, the photosensitizer is selected from the group consisting of nintedanib, Photofrin, talaporfin, verteporfin, and hexaminolevulinate. In one embodiment, the tumor is a bladder tumor, an esophagus tumor, a stomach tumor, a buccal tumor, a pharynx tumor, a colon tumor, a duodenal or other small intestine tumor, a lung tumor, a bronchial tumor, a skin tumor or other cancer/pre-cancer lesion or other skin lesion, pancreas tumor, brain tumor, eye tumor, or the like.

In a fourth aspect, the invention provides a pharmaceutical formulation containing a perfluorocarbon and an antiangiogenic medicament. In one embodiment, the perfluorocarbon is perflubron. In one embodiment, the antiangiogenic medicament is a VEGF antagonist. In one embodiment, the antiangiogenic medicament is an antibody, an antibody fragment, and aptamer, or a receptor Fc-fusion protein. In a specific embodiment, the antiangiogenic medicament is aflibercept. In one embodiment, the pharmaceutical formulation is contained in a vial or in a syringe (i.e., a pre-filled syringe).

In a fifth aspect, the invention provides a method for treating an eye disease comprising administering a pharmaceutical formulation of the fourth aspect to the eye of a patient in need thereof. In one embodiment, the pharmaceutical formulation is administered via intravitreal injection. In one embodiment, the eye disease is selected from the group consisting of wet age-related macular degeneration (AMD), macular edema due to retinal vein occlusion, diabetic macular edema, and diabetic retinopathy.

In a sixth aspect, the invention provides a method for treating cancer comprising administering a pharmaceutical formulation of the first or fourth aspect to the tumor of a patient in need thereof. In one embodiment, the pharmaceutical formulation is administered peritumorally, intravenously, subcutaneously, intratumorally, topically, or intravascularly (e.g., by injection).

DRAWINGS

FIG. 1 depicts a bar histogram depicting mean fluorescence intensity in arbitrary units at 700 nm as a function of tissue uptake of perflubron. The X-axis depicts tissues, where LN=lymph node.

FIG. 2 depicts a bar histogram depicting mean fluorescence intensity in arbitrary units at 800 nm as a function of tissue uptake of IRDye®-800CW-labeled cetuximab. The X-axis depicts tissues, where LN=lymph node.

FIG. 3 is a bar histogram depicting viable cell counts as a function of treatment. Treatments are PFCE30 (30% perflubron emulsion), PFCE10+IRR (10% perflubron emulsion plus infrared radiation), PFCE20+IRR (20% perflubron emulsion plus infrared radiation), PFCE30+IRR (30% perflubron emulsion plus infrared radiation), PFCE10+Cet-IR800+IRR (10% perflubron emulsion plus cetuximab linked to IRDye 800 plus infrared radiation), PFCE20+Cet-IR800+IRR (20% perflubron emulsion plus cetuximab linked to IRDye 800 plus infrared radiation), PFCE30+Cet-IR800+IRR (30% perflubron emulsion plus cetuximab linked to IRDye 800 plus infrared radiation). * =p<0.05 v. control. § =p<PFCE+Cet-800+IRR. ¶=p<v. respective PFCE+Cet-800+IRR.

DETAILED DESCRIPTION

In accordance with the present invention, a composition that is capable of delivering gas-based therapy and/or bioactive agents as well as methods of use have been discovered. The invention finds use in targeting cells in a subject harboring conditions or at risk for conditions that would benefit from such a therapy. In particular, the invention relates to the use of fluorochemical compositions for use as a delivery mechanism to targeted tissue and cells that results in retention of the fluorochemical composition and permits visualizing same along with any therapeutic agent, including gaseous substances and bioactive agents, delivered in combination with the fluorochemical composition.

I. Compositions

Compounds useful in this invention, such as those listed below (hereinafter called “fluorocarbons” or “fluorochemicals” or “perflubron” or “perfluorocarbons”), are generally able to promote gas exchange, and most of these fluorocarbons readily dissolve gaseous substances, including but not limited to oxygen or carbon dioxide.

A. Fluorocarbons

Fluorocarbon molecules used in the present invention may have various structures, including straight or branched chain or cyclic structures as known in the art. These molecules may also have some degree of unsaturation, and may also contain bromine or hydrogen atoms, or they may be amine derivatives. Typically, the fluorocarbon is a liquid or a gas at room temperature (25° C.). Preferably, the fluorocarbon has from about 2, 3, 4, or 5 carbon atoms to about 10, 12, or 14 carbon atoms. There are a number of fluorocarbons that are contemplated for use in the present invention. These fluorocarbons include but are not limited to bis(F-alkyl) ethanes such as C₄F₉CH═CH₄CF₉ (sometimes designated “F-44E”), i-C₃F₉ CH═CHC₆F₁₃ (“F-i36E”), and C₆F₁₃CH═CHC₆F₁₃ (“F-66E”) cyclic fluorocarbons, such as C10F18 (“F-decalin”, “perfluorodecalin” or “FDC”), F-adamantane (“FA”), F-methyladamantane (“FMA”), F-1,3-dimethyladamantane (“FDMA”), F-di- or F-trimethylbicyclo[3,3,1]nonane (“nonane”); perfluorinated amines, such as F-tripropylamine (“FTPA”) and F-tri-butylamine (“FTBA”), F-4-methyloctahydroquinolizine (“FMOQ”), F-n-methyl-decahydroisoquinoline (“FMIQ”), F-n-methyldecahydroquinoline (“FHQ”), F-n-cyclohexylpurrolidine (“FCHP”), F-2-butyltetrahydrofuran (“FC-75” or “RM101”) and other fluorocarbons known in the art.

Other fluorocarbons include brominated perfluorocarbons, such as but not limited to 1-bromo-heptadecafluoro-octane (C₈F₁₇Br, sometimes designated perfluorooctylbromide or “PFOB”), 1-bromopenta-decafluoroheptane (C₇F₁₅Br), and 1-bromotridecafluorohexane (C₆F₁₃Br, sometimes known as perfluorohexylbromide or “PFHB”). Other brominated fluorocarbons are disclosed in U.S. Pat. No. 3,975,512 to Long. Also contemplated are fluorocarbons having nonfluorine substituents, such as perfluorooctyl chloride, perfluorooctyl hydride, and similar compounds having different numbers of carbon atoms.

Additional fluorocarbons contemplated in accordance with this invention include perfluoroalkylated ethers or polyethers, such as but not limited to (CF₃)₂ CFO(CF₂CF₂)₂ OCF(CF₃)₂, (CF₃)₂ CFO—(CF₂CF₂)₃OCF(CF₃), (CF₃)CFO(CF₂CF₂)F, (CF₃)₂ CFO(CF₂CF₂)₂F, (C₆F₁₃)₂O. Further, fluorocarbon-hydrocarbon compounds, such as, for example compounds having the general formula C_(n)F_(2n+1)—C_(n′)F_(2n′+1)OC_(n′)F_(2n+1)OC_(n′)F_(2n′+1), or C_(n) F_(2n+1)CF═CHC_(n′)F_(2n′+1), where n and n′ are the same or different and are from about 1 to about 10 (so long as the compound is a liquid at room temperature). Such compounds, for example, include but are not limited C₈F₁₇C₂H₅ and C₆F₀CH═CHC₆H₁₃. It will be appreciated that esters, thioethers, and other variously modified mixed fluorocarbon-hydrocarbon compounds are also encompassed within the broad definition of “fluorocarbon” materials suitable for use in the present invention. Mixtures of fluorocarbons are also contemplated. Additional “fluorocarbons” not listed herein, but having those properties described in this disclosure that would lend themselves to use in accordance with the present invention are additionally contemplated.

The fluorocarbons used in the present invention may be used as neat liquid compositions, as gases, or as emulsions.

B. Fluorocarbon Emulsions

In one embodiment, the fluorocarbon compositions of the present invention will include an emulsifying agent to create a fluorocarbon emulsion. Such emulsions are typically fluorocarbon-in-water emulsions having a discontinuous fluorocarbon phase and a continuous aqueous phase. In an additional embodiment, emulsions with a continuous fluorocarbon phase and a discontinuous aqueous phase are also contemplated. The emulsions typically include any emulsifying agents used or known in the industry including but not limited to, osmotic agents, buffers, electrolytes and combinations thereof.

Although fluorocarbon concentrations from about 1% to 5% are possible and contemplated as low as 0.5% w/v are also possible. In another embodiment the concentrations of fluorocarbon are about 5% to at least 25% or 30%, preferably at least 40%, 50%, 55%, and may be 60%, 75% or 80% w/v. In an additional embodiment, emulsions containing up to 85%, 90%, 100%, and 125% fluorocarbon are also contemplated. Preferred fluorocarbon emulsion formulations are known in the art and include without limitation those disclosed in U.S. Pat. Nos. 4,865,836; 4,987,154; 4,927,623; and 6,204,296 which are hereby incorporated by reference.

1. The Emulsifying Agent

The fluorocarbon emulsions can also include an emulsifying agent. As used in this specification, an emulsifying agent is any compound or composition that aids in the formation and maintenance of the droplets of the discontinuous phase by forming a layer at the interface between the discontinuous and continuous phases. The emulsifying agent may comprise a single compound or any combination of compounds, such as in the case of co-surfactants.

In the present invention, emulsifying agents can include compounds known in the industry but are not limited to phospholipids, nonionic surfactants, fluorinated surfactants, which can be neutral or anionic, and combinations of such emulsifying agents.

Lecithin is a phospholipid that has frequently been used as a fluorocarbon emulsifying agent, as is more fully described in U.S. Pat. No. 4,865,836. Another example of an emulsifying agent for use with fluorochemical compositions is egg yolk phospholipids. See e.g., Long, U.S. Pat. No. 4,987,154.

Other emulsifying agents may be used with good effect, such as fluorinated surfactants, also known as fluorosurfactants. Fluorosurfactants that can provide stable emulsions include triperfluoroalkylcholate; perfluoroalkylcholestanol; perfluoroalkyloxymethylcholate; C₃F₇O(CF₂)₃C(═O)NH(CH₂)₃N(O)(CH₃)₂(XMO-10); and fluorinated polyhydroxylated surfactants, such as, for example, those discussed in “Design, Synthesis and Evaluation of Fluorocarbons and Surfactants for In Vivo Applications New Perfluoroalkylated Polyhydroxylated Surfactants” by J. G. Riess, et al. J. G. Riess et al., Biomat. Artif. Cells Artif. Organs 16: 421-430 (1988).

The nonionic surfactants suitable for use in the present invention include polyoxyethylene-polyoxypropylene copolymers. An example of such class of compounds is Pluronic, such as Pluronic F-68. Anionic surfactants, particularly fatty acids (or their salts) having 12 to 24 carbon atoms, may also be used. One example of a suitable anionic surfactant is oleic acid, or its salt, sodium oleate.

It will be appreciated by one of ordinary skill in the art that choice of a particular emulsifying agent is not central to the present invention. A number of emulsifying agents can be used and will depend on the target, fluorochemical, and bioactive agents used. Indeed, virtually any emulsifying agent (including those still to be developed) capable of facilitating formation of a fluorocarbon-in-water emulsion can form improved emulsions when used in the present invention. The optimum emulsifying agent or combination of emulsifying agents for a given application may be determined through routine empirical studies that do not require undue experimentation. Consequently, one practicing the art of the present invention should choose the emulsifying agent or combination of emulsifying agents for such properties as biocompatibility. In one embodiment, the emulsifying agent is any one or more of egg phosphatidylglycerol, dimyristoyl phosphatidylcholine, and the like.

2. Preparation of the Emulsion

Fluorocarbon emulsions according to the invention are prepared by means of conventional emulsification procedures, such as, for example, mechanical or ultrasonic emulsification of an emulsion formulation in a Manton-Gaulin mixer or Microfluidizer (Microfluidics Corp., Newton, Mass.). Any means known in the industry for creating an emulsion can be used.

Usually, a pre-emulsion mixture is prepared by simple mixing or blending of the various components. This pre-emulsion is then emulsified in the desired emulsification apparatus.

The combined fluorocarbon concentration in the emulsion is preferably anywhere within the range of about 20% to about 125% (w/v). In another embodiment the fluorocarbon concentration is 5% to about 20%. In preferred emulsions, the total perfluorocarbon concentration is from about 30%, 40%, or 50% to about 70%, 80%, 90%, or 100% (w/v). Emulsifiers are added in concentrations of from about 0.1% to 10%, more preferably 1% or 2% to about 6% (w/v).

The fluorocarbon can act to inhibit NfkB activation to aide in diminishing tumor progression (metastasis). In one embodiment, the fluorocarbon composition alone is the therapeutic agent. In certain embodiments, the fluorochemical composition is used in combination with at least one gas-based therapeutic. In certain embodiments, the fluorochemical composition is used in combination with at least one bioactive agent. In other embodiments, the fluorocarbon composition may be combined or co-administered with at least one gas-based therapeutic and at least one bioactive agent. In certain embodiments, more than one bioactive agent or gas-based therapeutic may be combined with the fluorocarbon composition. Such compounds may be administered to the subject simultaneously or sequentially. For example, in one topical administration or oral buccal cavity wash embodiment, the fluorocarbon (e.g. perflubron) is administered topically, and then followed by the topical administration of the photosensitizer (e.g., verteporfin, hexaminolevulate [HAL], or the like) prior to PDT. In an alternative embodiment, the photosensitizer is administered first, then followed by administration of the fluorocarbon, both prior to PDT. A fluorochemical composition of the invention may be administered to a subject in conjunction with at least a second compound known in the art to benefit treating the target microenvironment. The amount of gas or bioactive agent administered to a subject in conjunction with a fluorochemical composition will depend on the desired dosage prescribed to treat the target.

The fluorochemical will penetrate throughout the tumor. The uptake of the fluorochemical into the tumor stroma will allow identification or visualization of the tumor and simultaneously inhibit the same tumor macrophages and fibroblasts. Further, the fluorochemical can be combined with an amount of another bioactive agent administered before, during, or after administrating the fluorochemical so as to aid the delivery of the bioactive agent to the tumor or desired location for treatment. Penetration of these agents aids in overall treatment of a patient. The specific perfluorooctyl bromide (neat or emulsified), also known as perflubron, has demonstrated anti-macrophage and anti-fibroblast activity. International Patent Application No. WO2012003457A1 is incorporated herein for teaching the anti-fibroblastic activity of the perfluorocarbon perfluorooctyl bromide.

C. Gas-based Therapy

In one embodiment, the fluorocarbon composition is combined with a gas. Suitable gases include any therapeutic, bioactive, or diagnostic gas or gas composition known in the art or yet to be discovered, as well as combinations thereof, that may be administered to a subject. The precise amount of gas used in combination with the composition of the present invention is dependent upon the target, the agent of choice, the required dose, and the specific nature of the gas that is actually combined with the composition. Those skilled in the art will appreciate that such determinations may be made by using well known techniques in combination with the teachings of the present invention.

Preferred gas and gas compositions may comprise, but are not limited to oxygen, carbon dioxide, nitrogen, helium, hydrogen sulphide, nitric oxide, neon, argon, krypton, xenon, radon, sulfur hexafluoride, carbon monoxide, hydrogen, chlorine, fluorine, ethane, and combinations thereof.

D. Bioactive Agents

In one embodiment, the fluorocarbon composition is combined with a bioactive compound. Suitable bioactive agents include any therapeutic, bioactive, or diagnostic compound or composition known in the art or yet to be discovered, as well as combinations thereof, that may be administered to a subject. In certain embodiments, the bioactive agent is at least one metabolic inhibitor, chemotherapy agent, radiation agent, beneficial agent, or a combination thereof. In some cases, the photosensitizer is a bioactive agent (e.g., verteporfin has demonstrated biological activity beyond its photosensitizing activity). The precise amount of bioactive agent used in combination with the composition of the present invention is dependent upon the target, the agent of choice, the required dose, and the form of the agent actually combined with the composition. Those skilled in the art will appreciate that such determinations may be made by using well known techniques in combination with the teachings of the present invention.

1. Metabolic inhibitors

Metabolic inhibitors include bioactive molecules capable of affecting metabolic processes relied upon by cancer or pre-cancerous cells. Inhibition of these pathways aide in blocking the tumors fuel. Any metabolic process-affecting molecule known in the art or yet to be discovered is contemplated herein. Suitable metabolic processes that may be affected include, without limitation, nucleic acid synthesis, amino acid metabolism, protein synthesis, lipid synthesis, glycolysis, mitochondrial metabolism, TCA cycle, fatty acid metabolism, glycolytic, NAD metabolism, phosphoinositide 3-kinase signal transduction and any other metabolic process relied upon by cancer or pre-cancerous cells. Suitable nucleic acid synthesis inhibitors include, without limitation, methotrexate, pemetrexed, 5-fluorouracil, hydroxyurea, gemcitabine, fludarabine, ribose synthesis inhibitors (i.e. transketolase-like protein 1 and glucose-6-phosphate dehydrogenase inhibitors), folate metabolism inhibitors, thymidine synthesis inhibitors, deoxynucleotide synthesis inhibitors, and nucleotide incorporation inhibitors. Suitable amino acid metabolism/protein synthesis inhibitors include, without limitation, L-asparaginase, arginine deiminase conjugated to polyethylene glycol, glutamine inhibitors, and phosphoglycerate dehydrogenase inhibitors. Suitable lipid synthesis inhibitors include fatty acid synthase inhibitors, ATP citrate lyase inhibitors, and acetyl-CoA carboxylase inhibitors. Suitable glycolysis inhibitors include 2-deoxyglucose, 2-deoxy-D-glucose, 2-deoxy-2-[18f]fluoro-D-glucose, glucose transport inhibitors, phosphofructokinase 2 inhibitors, phosphoglycerate mutase inhibitors, pyruvate kinase M2 inhibitors, lactate dehydrogenase A inhibitors, and lactate excretion inhibitors. Suitable mitochondrial metabolism inhibitors include dichloroacetate (DCA), isocitrate dehydrogenase inhibitors, malic enzyme inhibitors, mitochondrial complex I inhibitors, metformin, glutamine availability inhibitors, and pyruvate carboxylase inhibitors. Suitable fatty acid metabolism inhibitors may include monoacylglyceral lipase inhibitors and carnitine palmitoyltransferase 1C inhibitors. Suitable NAD metabolism inhibitors may include nicotinamide phosphoribosyltransferase (NAMPT) inhibitors such as bMPC-9528. Additional effectors of metabolic processes include, without limitation, insulin-like growth factor inhibitors, mTOR inhibitors such as rapamycin, VEGF inhibitors such as avastin, and HIF1-alpha inhibitors such as PX-478.

2. Chemotherapy agents

Exemplary embodiments of chemotherapy agents include, without limitation, actinomycin D (Cosmegen), aldesleukin (Proleukin), alitretinoin (Panretin), all-trans retinoic acid/ATRA (Tretinoin), altretamine (Hexalen), amascrine, asparaginase (Elspar), azacitidine (Vidaza), azathioprine (Imuran), bacillus calmette-guerin/BCG (TheraCys, TICE BCG, TICE), bendamustine hydrochloride (Treanda), bexarotene (Targretin), bicalutamide (Casodex), bleomycin (Blenoxane), bortezomib (Velcade), busulfan (Busulfex, Myleran), capacitabine (Xeloda), carboplatin (Paraplatin), carmustine bcnu (BiCNU), chlorambucil (Leukeran), cisplatin/cisplatinum (Platinol, Platinol-AQ), cladribine (Leustatin), cyclophosphamide/cytophosphane (Cytoxan, Endoxan, Neosar, Procytox, Revimmune), cytabarine (Cytosar-U), dacarbazine (DTIC-Dome), daunorubicin/daunomycin (DaunoXome, Cerubidine), denileukin diftitox (Ontak), dexrazoxane (Zinecard), docetaxel (Taxotere), melphalen, doxorubicin (Adriamycin, Rubex), doxorubicin (Doxil), doxorubicin liposomal (Doxil), epirubicin (Ellence), etoposide (Eposin, Etopophos, Toposar, Vepesid, VP-16), fludarabine (Fludara), fluorouracil 5-FU (Adrucil), gemcitabine (Gemzar), goserelin (Zolodex), hydrocortisone (Solu-Cortef), hydroxyurea (Hydrea), idarubicin (Idamycin), ifosfamide (Ifex, Mitoxana), interferon alfa (Intron-A, Roferon-A), irinotecan CPT-11 (Camptosar), lapatinib (Tykerb), lenalidomide (Revlimid), leuprolide (Eligard, Lupron, Lupron Depot, Viadur), mecholorethamine/chlormethine/mustine/HN2 (Mustargen), mercaptopurine (Purinethol), methotrexate (Rheumatrex), methylprednisolone (Solu-Medrol), mitomycin (Mutamycin), mitotane (Lysodren), mitoxantrone (Novantrone), octreotide (Sandostatin, Sandostatin LAR), oprelvekin (Neumega), oxaliplatin (Eloxatin, Oxaliplatin Medac), paclitaxel (Taxol, Onxal), paclitaxel protein-bound (Abraxane), pamidronate (Aredia), pazopanib (Votrient), pegaspargase (Oncospar), pegfilgrastim (Neulasta), PEG interferon (PEG-INTRON), Pemetrexed (Alimta), Pentostatin (Nipent), Phenylalanine mustard (Alkeran), plicamycin/mithramycin (Mithracin), prednisone (Deltasone, Liquid Pred, Meticorten, Orasone), prednisolone (Delta-Cortef, Orapred, Pediapred, Prelone), procarbazine (Matulane), raloxifene (Evista), romiplostim (Nplate), sargramostim (Leukine), sorafenib (Nexavar), streptozocin (Zanosar), sunitinib (Sutent), tamoxifen (Novaldex), temozolomide (Temodar), temsirolimus (Torisel), teniposide (Vumon, VM-26), thalidomide (Thalomid), thioguanine (Thioguanine Tabloid), thiophosphoamide/thiotepa (Thioplex), thiotepa (Thioplex), topotecan hydrochloride (Hycamtin), toremifene (Fareston), tretinoin (Vesanoid), valrubicin (Valstar), vinblastine (Velban, Alkaban-AQ), vincristine (Oncovin, Vincasar, Vincrex), vindesine (Eldisine), vinorelbine (Navelbine), vorinostat (Zolinza), zoledronic acid (Zometa), and the like. In addition, heated intraperitoneal chemotherapy (HIPEC) can be used.

Chemotherapy agents also include antibody-based therapies including, without limitation, alemtuzumab (Campath), bevacizumab (Avastin), cetuximab (Erbitux), gemtuzumab ozogamicin (Mylotarg), ibritumomab tiuxetan (Zevalin), ofatumumab (Arzerra), panitumumab (Vectibix), rituximab (Rituxan, Mabthera), tositumomab (Bexxar), trastuzumab (Herceptin), and trastuzumab DM1 (Herceptin DM1). In some embodiments, monoclonal antibodies are combined with dyes such as near infrared dyes (IRDyes) or other similar fluorescent agents. In other embodiments, monoclonal antibodies are combined with dyes, such as near infrared dyes (IRDye's) or other similar fluorescent agents, and a quencher. Here, the quencher serves to quench the fluorescent signal when the combination is not engaged with the specific target, and upon target engagement, the quencher is sufficiently separated from the fluorophore to enable visualization or quantification of the fluorescent emission.

Further, chemotherapy agents include tyrosine-kinase inhibitor (TKI) based therapies including, without limitation, axitinib, afatinib, regorafenib, bafetinib, bosutinib, cediranib (Recentin), crizotinib, dasatinib (Sprycel), erlotinib hydrochloride (Tarceva), gefitinib (Iressa), imatinib (Gleevec, Glivec), lapatinib (Tykerb/Tyverb), lestaurtinib, neratinib, nilotinib (Tasigna), nintedanib, ponatinib, quizartinib, regorafenib, ruxolitinib, sunitibin (Sutent), tofacitinib, vandetanib (Zactima), N-acetylcysteine, and vatalanib. In addition the anti-cancer agent can include anti-virals including by not limited to Ribavirin. In some embodiments, the TKI is combined with fluorescent or other molecules, which enables multi-targeting of stroma and cancer cells.

3. Radiation agents

Exemplary embodiments of radiation agents include radiation-based therapies such as external radiation, brachytherapy, systemic radiation, use of radiosensitizers and radioprotectors, and carbon ion beams. By way of example, radiation-based therapies may include, without limitation, x-rays, gamma rays, antibody targeted radiation, seed implant radiation, and other radiation therapies known in the art or yet to be discovered. Antibody targeted radiation may include ibritumomab tiuxetan (Zevalin), tositumomab and iodine-131 (Bexxar), samarium-153 lexidronan (Quadramet), strontium-89 chlorine (Metastron), and others known in the art or yet to be discovered.

4. Beneficial agents

Exemplary beneficial agents may comprise but are not limited to respiratory agents, antibodies, antibiotics, antivirals, mydriatics, antiglaucomas, anti-inflammatories, antihistaminetics, antineoplastics, anesthetics, ophthalmic agents, cardiovascular agents, active principles, nucleic acids, genetic material, immunoactive agents, imaging agents, immunosuppressive agents, gastrointestinal agents, hyaluron (HA) and combinations thereof. Further exemplary embodiments of the present invention comprise anti-inflammatory agents such as the glucocorticosteroids (i.e. cortisone, prednisone, prednisolone, dexamethasone, betamethasone, Beclomethasone diproprionate, Triamcinolone actinide, Flunisolide) xanthines (i.e. theophylline, caffeine), antibiotics (i.e. aminoglycosides, penicillins, cephalosporins, macolides, quinolones, tetracyclines, chloramphenicol), bronchodilators such as the B₂-agonists (i.e. adrenaline, isoprenaline, salmeterol, albuterol, salbutamol, terbutaline, formoterol) and surfactants. Still other exemplary embodiments include a/B adrenergic blockers (i.e. Normodyne®, Trandate®), angiotensin converting enzyme inhibitors (i.e. Vasotec®), antiarrhythmics, beta blockers, calcium channel blockers, inotropic agents, vasodilators, vasopressors, anesthetics (i.e. morphine) and ophthalmic agents (i.e. Polymyxin B, Neomycin, Gramicidin).

Beneficial agents may also include collagenases. Any bioactive agent capable of breaking peptide bonds in collagen is contemplated herein. Exemplary collagenases include, without limitation, collagenase Clostridia Histolyticum (Xiaflex®).

In accordance with the present invention, those skilled in the art will appreciate that various bioactive agents may be used in combination with the compositions of the present invention and selection of the bioactive agents used depends upon the intended use of the invention. Further, those skilled in the art will appreciate that various forms of these compounds may be used to modify the therapeutic index of the bioactive agents.

Because the compositions of the present invention are uniquely suited for use in a wide variety of physiological applications such as topical, ocular, oral, pulmonary, rectal, subcutaneous, intratumoral, intramuscular, intraluminal, intraperitoneal, nasal, vaginal, mucosal (gut tube included esophagus, colon, and the like) or aural administration of medicaments or diagnostic compounds, a wide variety of bioactive agents may be incorporated therein. Accordingly, the foregoing list of bioactive agents is not intended to limit the present invention in any way.

Another advantage provided by the present invention is the ability to use the free base form of the incorporated bioactive agent rather than its less efficacious salt form. That is, the efficacy of lipophilic forms of drugs has been shown in many instances to be more potent than the less lipophilic forms of the agent, (i.e. the salts). The nonreactive nature of the fluorochemical compositions allows the incorporation of particularly efficacious base forms of the selected pharmaceutical agent. As those skilled in the art will appreciate, the use of these more potent agent forms enhances the bioavailability of the incorporated pharmaceutical agent and reduces the dosages which must be administered.

The present invention may optionally contain at least one nonfluorinated co-solvent to facilitate the combination of a bioactive agent in the fluorochemical composition. Preferably, the concentration of the nonfluorinated co-solvent comprises up to about 50% v/v of the fluorochemical composition. Suitable co-solvents include any of those known in the art or yet to be discovered. Exemplary co-solvents include ethers, alcohols, alkyl sulfoxides and combinations thereof. Preferably the co-solvents are short chain alcohols (i.e. carbon chain length ≤4 carbons) or an alkyl sulfoxide such as dimethylsulfoxide. More preferably, the co-solvent is ethanol.

The compositions of the present invention may optionally include one or more additives. Any additive that provides benefit to the intended use of the present invention is contemplated and includes additives known in the art and yet to be discovered. Exemplary additives include mineral salts, buffers, oncotic and osmotic agents, nutritive agents, flavorings, or palatability enhancers, or any other ingredient capable of augmenting the favorable characteristics of the compositions of the present invention including pharmaceutical stability, therapeutic efficacy and tolerance.

The compositions may also include additives for use in monitoring the delivery and potential absorption at a selected target of the composition including but not limited to colorings, dyes, or tracking agents. The monitoring agents such as dyes are used in conjunction with the composition to monitor the delivery of the composition to ensure optimum delivery and coverage of the selected target. The perflurocarbon can be actively monitored with the use of conventional x-rays, cat-scans, MM imaging, ultrasound and spectroscopy such as Raman spectroscopy. The monitoring can further be enhanced with the addition of certain additives or agents that allow a user to monitor and track the delivery and uptake of the composition at the desired target. Further, those skilled in the art will understand that many monitoring agents or additives could be used and will depend on the target site and treatment used.

5. Photosensitizers

As used herein, the term “photosensitizer” means any molecule that absorbs light. In some embodiments, the photosensitizer is a fluorescent molecule. In some embodiments, the photosensitizer has biological activity (e.g., nintedanib, which has PKI activity as well as having the ability to undergo Type I and/or Type II photochemical reactions to form reactive oxygen species, and verteporfin). In other embodiments, the photosensitizer is combined with or linked to a biologically active molecule such as an antibody or antibody fragment (e.g., LUCENTIS), an aptamer (e.g., MACUGEN), a fusion protein (e.g., aflibercept), or a small molecule (<900 Daltons) drug (e.g., nintedanib). All fluorescent molecules are photosensitizers as that term is used herein. Fluorescent molecules and other photosensitizers include those molecules known in the art to be used in conjunction with photodynamic therapy, such as for example aminolevulinic acid (5-ALA), hexaminolevulinate (HAL), talaporfin (Laserphyrin) (TAL), porfimer sodium (Photofrin), a benzoporphyrin derivative (verteporfin), as well as fluorophores such IR700 (IRDye 700), IR800 (IRDye 800), rhodamine and derivatives, fluorescein and derivatives, and the like, as well as those molecules that are generally not regarded as canonical fluorophores or photosensitizers, but nonetheless do in fact absorb higher energy radiation and emit lower energy radiation, such as for example nintedanib, which exhibits fluorescent properties.

Tetrapyrrole structures such as porphyrins, which include Photofrin, protoporphyrin IX, 5,10,15,20-tetrakis(1-methylpyridinium-4-yl) porphyrin tosylate, and XF-70; chlorins, which include Radachlorin, Foscan, Verteporfin, chlorin(e6), monoaspartyl chlorin(e6) (Talaporfin sodium), and HPPH; bacteriochlorins, which include TOOKAD Soluble (WST-11), LUZ11, BC19, and BC21; and phthalocyanines, which include liposomal ZnPC, chloroaluminium sulfonated phthalocyanine (CASP), Silicon phthalocyanine (PC4), and RLP068 are useful photosensitizers. Additionally, dyes, including synthetic dyes, are useful photosensitizers. Useful synthetic dyes include phenothiazinium salts, such as methylene blue, toluidine blue 0, and PP904, Benzophenothiazinium salts such as EtNBS, halogenated xanthenes such as Rose Bengal, squaraines such as ASQI, boron-dipyrromethene compounds (BODIPYs) such as Zinc(II)-dipicolylamine di-iodo-BODIPY and DIMPy-BODIPY, phenalanones, transition metal complexes such as ruthenium complexes, rhodium complexes, and iridium complexes, and natural compounds such as the perylenequinones hypericin and hypocrellin, flavins such as cationic riboflavin, and curcuminoids such as curcumin. See Abrahamse and Hamblin, “New photosensitizers for photodynamic therapy,” Biochem J. 2016 Feb. 15; 473(4): 347-364, and the references disclosed therein, which are herein incorporated for disclosing photosensitizers that are useful in photodynamic therapy.

In one embodiment, the photosensitizer is Photofrin, which is currently approved by the US FDA for PDT of obstructing (tubes) lungs and esophagus. Photofrin is a mixture of oligomers formed by ether and ester linkages of up to eight porphyrin units. In one embodiment, the Photofrin is injected into a vein of a patient in which oxygen-charged perfluorocarbon had been administered, thereby enabling the rapid uptake of Photofrin into the tumor or cancer cells. 40 hours later, PDT is performed with a shortened time that is less than the standard 12 1/2 to 25 minutes.

II. Methods

The present invention encompasses methods of targeting tissue cells in or on a subject harboring conditions or at risk for conditions that would benefit from gas-based and/or photodynamic therapy. The methods may be utilized to treat a subject harboring a condition that would benefit from gas-based and/or photodynamic therapy or that is at risk of developing a condition that would benefit from such therapy.

In one embodiment, the use of a perfluorocarbon emulsion, preferably perfluorooctyl bromide with demonstrable anti-stromal properties(i.e., perflubron), combined with a photosensitizer such as a near infrared dye (e.g., IRDye® 800CW, IRDye® 700DX, IRDye® 680LT, and IRDye® 680RD [LI-COR, Inc., Lincoln, Nebr.]; preferably IRDye® 800CW or IRDye® 700DX) coupled to an antibody or other antigen-binding protein (e.g., panitumumab, bevacizumab, cetuximab), or small molecule such as a tyrosine kinase inhibitor (e.g., nintedanib) using oxygen gas therapy to treat tumors, microtumors, and/or other cancer forms with photodynamic therapy (PDT).

The inclusion of the anti-stromal perfluorocarbon with the anti-cancer drug mitigates cancer “rescue” by inhibiting stroma. Without residual stromal cells, remnant cancer cells cannot use those cells to recover and return. Furthermore, the inclusion of perfluorocarbon with the cancer drug-IR dye conjugate enables increased delivery of oxygen to the tumor to enhance PDT killing and also reduces hypoxia, which may reduce tumor aggressiveness.

In another embodiment, the tumor (cancer cells and/or stroma) can be ablated using precise high intensity focused ultrasound therapy along with the administration of perfluorocarbon and photosensitizer. Shin et al., “Tracking Perfluorocarbon Nanoemulsion Delivery by 19F MRI for Precise High Intensity Focused Ultrasound Tumor Ablation,” Theranostics. 2017 Jan. 7; 7(3): 562-572 is incorporated herein by reference for teaching magnetic resonance imaging to quantitatively track perfluorocarbon nanoemulsions (PFCNE) accumulation in a tumor, and analyzing how intra-tumoral PFCNE quantities affect the therapeutic efficacy of high intensity focused ultrasound (HIFU) treatment.

A. Conditions Benefiting from Gas-Based Therapy

Conditions that would benefit from gas-based therapy, such as treatment with the fluorochemical composition, may include any condition or disease that is altered from normal physiological homeostasis. For instance, exemplary conditions that may benefit from gas-based therapy include, but are not limited to, sites of tissue injury, degeneration, neoplastic growth, dysplasia, hyperplasia, neoplasia, tumor formation, tumor growth, cancer, including but not limited to pancreas, ovarian, colon, liver, peritoneal, bladder, skin, head and neck, lung, brain, glioblastoma, breast and sarcoma, tumor stroma, tumor nests, tumor associated fibroblasts, myofibroblasts, SMA positive cells, tumor associated macrophages, CD68, M1 macrophages, M2 macrophages, tumor stem cells, dendritic cells, lymphocytes, broncho-pulmonary dysplasia, osteoarthritis, and other conditions known in the art or yet to be discovered that may benefit from gas-based therapy. Further exemplary conditions may include, without limitation, acneiform eruptions, acute interstitial pneumonitis, autoinflammatory syndromes, arthritis, asthma, atherosclerosis, autoimmune diseases, Barrett's disease, bronchiolitis obliterans with organizing pneumonia, cancer chlorioretinal scarring, chronic blistering, chronic prostatitis, cirrhosis, colitis, connective tissue diseases, corneal scarring, Crohn's disease, dermal and subcutaneous growths, dermatitis, dermatomyositis, desquamative interstitial pneumonitis, diverticulitis, eosinophilic cutaneous conditions, epidermal cysts, epidermal neoplasms, epidermal nevi, fibromyalgia, glaucoma, glomerulonephritis, hepatitis, hypertrophic scarring, inflammatory bowel diseases, inflammatory demyelinating polyneuropathy, inflammatory myopathies, interstitial cystitis, interstitial lung disease, irritable bowel syndrome, ischemic heart disease, keloidal scarring, Lofgren syndrome, lupus, lupus erythematous, lymphocytic interstitial pneumonitis, macular degeneration, nephritis, nonspecific interstitial pneumonitis, osteoporosis, Parkinson's, pelvic adhesive disease, pelvic inflammatory disease, polymyalgia rheumatica, polymyositis, port wine stain, reperfusion injury, respiratory distress, respiratory bronchiolitis, retinal diseases, rheumatoid arthritis, sarcoidosis, skin grafts, spinal cord injuries, surgical scarring, systemic sclerosis, transplant rejection, ulcerative colitis, and vasculitis as well as others known in the art or yet to be discovered.

Also, methods of the invention may be utilized to treat a population of cells that would benefit from gas-based therapy. Such cells include those in a subject as well as those removed from a subject for therapeutic treatment, cultured cells, those used in gene-therapy practices, and any other cell that may benefit from gas-based therapy.

B. Methods of the Invention

Generally, methods of the present invention include administering to a subject a fluorochemical composition of the invention for use as a delivery mechanism to targeted cells and tissue. In one embodiment, the fluorochemical composition is a liquid. In another embodiment, the fluorochemical composition is an emulsion. In one embodiment, the fluorochemical composition is used to deliver to and enhance the retention of additional therapeutic agents, including gas-based therapeutics and bioactive agents, at targeted cells and tissues. In another embodiment, the fluorochemical composition is itself a therapeutic agent.

In one embodiment, the fluorochemical composition is delivered systemically. In another embodiment, the fluorochemical composition is delivered directly at the target site. In yet another embodiment, the fluorochemical composition is delivered via installation (instilling).

In certain embodiments, the fluorochemical composition is administered in combination with at least one additional therapeutic agent. In certain embodiments, the fluorochemical composition is administered sequential to an additional therapeutic agent and/or photosensitizer. In other embodiments, the fluorochemical composition is administered prior to the administration of an additional therapeutic agent or photosensitizer. In certain embodiments, the fluorochemical composition is administered prior to and after the administration of an additional therapeutic agent or photosensitizer. In other certain embodiments, the fluorochemical composition is administered at the same time as at least one therapeutic agent or photosensitizer. In certain embodiments, the fluorochemical composition may be administered without additional therapeutic agents. By way of example, the fluorochemical composition may be mixed with such gas before administration or administered in combination. For example, the gas may be added directly to the composition or provided to the subject through other means such as direct instillation of the gas in addition with a therapeutic agent (gemcitabine 10 mg/ml).

Methods of the invention include administering to a subject a fluorochemical composition as a delivery vehicle for other agents including agents used in imaging applications, bioactive agents, gas-based therapeutics, or combinations thereof. The properties and characteristics of a fluorochemical composition specifically target the composition and enhance the retention of the composition at target sites. Also, the properties and characteristics of a fluorochemical emulsion composition specifically aide in delivery of the composition (including the agent) to the target and enhance the retention of the composition at target sites. The activity of the fluorochemical acts with the agent causing a synergistic therapeutic effect. In one embodiment, the fluorochemical composition includes an emulsifying agent to create a fluorochemical emulsion composition. In another embodiment the fluorochemical composition is in a neat form without an emulsifying agent. In yet another embodiment, the fluorochemical composition is instilled or topically applied to the target location. The fluorochemical composition may be used to target an agent to a location in a subject such that the retention time of the agent is improved compared to using the agent alone. The agent may be combined with the fluorochemical composition prior to administration. The fluorochemical composition and agent may work synergistically to benefit the subject.

Another embodiment includes administering to a subject a fluorochemical composition of the invention prior to a secondary therapy, and/or sensitizing the target area before the secondary therapy. Suitable secondary therapies include irradiation therapy, chemotherapy, combinations thereof and other therapies known in the art or yet to be discovered that would have enhanced efficacy following sensitization of the target area with compositions of the present invention. In one embodiment, the fluorochemical composition is used as a pre-treatment to the target area. Delivery of the fluorochemical composition as a pre-treatment enhances the gas delivery to the target area creating a better environment for enhancing the efficacy of the treatment therapeutic at the target area.

Methods of the invention include administering compositions of the present invention to a subject for the treatment of cancer. In one embodiment, the fluorochemical composition is aerosolized. In another embodiment, the fluorochemical composition is instilled. In another embodiment, the fluorochemical composition is topically applied. In one embodiment, the fluorochemical composition includes an emulsifying agent. In another embodiment, the fluorochemical composition is in a neat form without an emulsifying agent. For instance, the compositions are injected intravenously, topically applied, instilled or aerosolized directly at the site of tumor growth either alone or in combination with other therapeutics including gas-based therapeutics. Such methods are beneficial in the treatment of any and all cancer types known in the art or yet to be discovered. Exemplary cancer types to be treated include but are not limited to acute lymphoblastic leukemia, acute myeloid leukemia, adrenocortical carcinoma, anaplastic large cell lymphoma, appendix cancer, basal cell carcinoma, B cell cancer, bile duct cancer, bladder cancer, bone cancer (IGF-1 sensitive bone tumors), brain cancer, breast cancer, carcinoid tumor, cardiovascular cancer, cervical cancer, chronic lymphocytic leukemia, chronic myelogenous leukemia, colon cancer, colorectal cancer, epithelial carcinoma, epithelial cell-derived neoplasia, esophageal cancer, Ewing's sarcoma, gastric carcinoma, gastrointestinal cancer, gastrointestinal stromal tumors, glioblastoma multiforme, head and neck cancer, Hodgkin's lymphoma, kidney cancer, leukemia, lip cancer, liver cancer, lymphocytic leukemia, lymphoma, lung cancer, medulloblastoma, merkel cell carcinoma, melanoma, mouth cancer, multiple myeloma, Non-Hodgkin's lymphoma, non-small cell lung cancer, oropharyngeal cancer, osteosarcoma, ovarian cancer, pancreatic cancer, PD-L1 or PD-L2 expressing cancer cells, prostate cancer, rectal cancer, renal cell carcinoma, retinoblastoma, skin cancer (squamous cell cancer, basal cell cancer), small bowel cancer, small intestine cancer, large intestine cancer, soft tissue sarcoma, stomach cancer, and testicular cancer as well as other cancers known in the art.

C. Delivery Means and Routes

Methods of administration include any method known in the art or yet to be discovered. Exemplary administration methods include intravenous, intraocular, intratracheal, intratumoral, oral, rectal, topical, intramuscular, intraarterial, intrahepatic, intrathoracic, intrathecal, intracranial, intraperitoneal, intrapancreatic, intrapulmonary, gastrointestinal or subcutaneously.

The fluorochemical composition may be administered directly by instillation or as an aerosol. One skilled in the art will appreciate that the route of administration and method of administration depend upon the intended use of the compositions, the location of the target area, and the condition being treated in addition to other factors known in the art such as subject health, age, and physiological status. A skilled artisan will also recognize that methods using aerosol compositions may use a catheter placed through an appropriate scope and aerosolizing the composition using a nebulizer. Suitable nebulizers are known in the art. Exemplary nebulizers include but are not limited to the Aeroprobe™, Microsprayer™, Aerotech II™, Pari™ brand, or Aeroclipse™. Alternatively, the compositions may be aerosolized using dry methods known in the art such as a dry powder inhaler or similar device. In one embodiment, the fluorochemical composition is administered via an endoscopy spray catheter.

In one embodiment, the fluorochemical-containing compositions (e.g., PIRC or other combination compositions containing perfluorocarbon or perfluorocarbon emulsion and near infrared labeled drug [e.g., IR800 labeled nintedanib] or targeting molecule (IR800 labeled cetuximab]) are nebulized to produce particles (aerosolized) with a minimum diameter of at least 250 to 1000 nanometers (nm) and a maximum diameter of no greater than 10 microns (μm), or at least ≤5.8 μm, ≤5.7 μm, ≤5.6 μm, ≤5.5 μm, ≤5.4 μm, ≤5.3 μm, ≤5.2 μm, ≤5.1 μm, ≤5.0 μm, ≤4.9 μm, ≤4.8 μm, ≤4.7 μm, ≤4.6 μm, ≤4.5 μm, ≤4.4 μm, ≤4.3 μm, ≤4.2 μm, ≤4.1 μm, or ≤4.0 μm. In some embodiments ≥50%, ≥55%, ≥60%, ≥65%, ≥70%, ≥75%, ≥80%, ≥85%, ≥90%, or ≥95% of the aerosol particles have a diameter ≤5.8 μm or about 5-6 μm.

Fluorochemical compositions of the invention are typically administered to a subject in an amount sufficient to provide a benefit to the target microenvironment of the subject. This amount is defined as a “therapeutically effective amount.” The fluorochemical can be administered at ambient (temperature, pressure, etc.), conditions, below ambient conditions, above ambient conditions. Further the fluorochemical can be administered with bioactive agents at, below, or above ambient conditions. The therapeutically effective amount will be determined by the efficacy or potency of the particular composition, the duration or frequency of administration, and the size and condition of the subject, including that subject's particular treatment response. Additionally, the route of administration should be considered when determining the therapeutically effective amount. It is anticipated that the therapeutically effective amount of a fluorochemical composition of the invention will range from about 0.1 ml/kg to about 35 ml/kg. Depending on the target area and desired therapeutic agent used in conjunction (of in certain instances no additional therapeutic agent will be used) with the fluorochemical composition the amount of fluorochemical can include 0.01%, 1%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 99%, or 100% of the total therapeutic composition. In determining the therapeutically effective amounts, one skilled in the art will also consider the existence, nature, and extent of any adverse effects that accompany the administration of a particular compound in a particular subject.

III. Kits

The present invention provides articles of manufacture and kits containing materials useful for treating the conditions described herein. The article of manufacture may include a container of a compound as described herein with a label. Suitable containers include, for example, bottles, vials, and test tubes. The containers may be formed from a variety of materials such as glass or plastic. The container holds a composition having an active agent which is effective for treating, for example, conditions that benefit from gas-based therapy. The active agent is at least one fluorochemical composition of the invention and may further include additional fluorochemicals or bioactive agents known in the art for treating the specific condition. The label on the container may indicate that the composition is useful for treating specific conditions and may also indicate directions for administration. In one embodiment, the kit contains silicone gel, perflubron emulsion, and a photosensitizer, such as e.g., verteporfin or HAL. In one embodiment, each ingredient is separately contained. In another embodiment, two or more of each ingredient are combined. In yet another embodiment, the photosensitizer and perflubron emulsion are combined or to be combined with the silicone gel.

IV. Methods of Detection and Treatment

In accordance with the present invention, compositions and methods for the imaging and/or pre-treatment of lymphatic channels and lymph nodes prior to surgical resection are provided. In other embodiments, the method is used to image and/or treat non-cancer conditions, such as inter alia interstitial pulmonary fibrosis, atherosclerosis, and other fibrotic conditions. In other embodiments, the invention provides theranostic methods of detecting and treating cancer, pre-cancerous tissue, dysplasias, such as focal cortical dysplasia, colon dysplasia, Barrett's esophagus with dysplasia and without dysplasia. By theranostic, the method enables concurrent or sequential identification of cells or tissue of interest and the treatment or killing of said cells or tissue.

In one aspect, a therapeutic composition that comprises (i) a fluorochemical emulsion (e.g., perflubron) and (ii) a biological molecule complexed with (iii) a label is administered to a subject, and a laser or other form of electromagnetic radiation (EMR) is applied to the subject in a manner that excites the label. In some embodiments, the fluorochemical emulsion is charged with O₂. Without wishing to be bound by theory, the biological molecule serves to home-in on and bind to a target, thereby labeling the target molecule or cell that expresses the target molecule. The label is subsequently excited by the applied electromagnetic radiation and emits EMR of a wavelength that generates toxic reactive oxygen species around and within the target cell. This is known as photo-dynamic therapy (PDT). The oxygen charged fluorocarbon emulsion delivers an abundant supply of oxygen to enable the persistence of the reactive oxygen species sufficient to destroy the labeled cell and proximal cells, thereby rendering PDT much more effective.

Alternatively, the composition containing the fluorochemical emulsion (e.g., perflubron) and biological molecule complexed with a label is administered as a method of detecting target-specific cells in a subject. The laser or other light of a particular wavelength or range of wavelengths is shone onto the suspect tissue of the subject, and light emitted by the excited label returning to ground state is detected.

Thus, in one embodiment, the O₂-charged fluorocarbon emulsion plus labeled target-binding moiety composition (“O₂*”) is delivered to a tissue or organ suspected of harboring a cancer cell, neoplastic, dysplastic or fibrotic tissue. The O₂* composition may be delivered to the target tissue by one or more of several routes. In one embodiment, the O₂* composition is delivered as an aerosol via an aerosolizing device, including for example an inhaler, a nebulizer, a small volume nebulizer, a pressurized metered-dose inhaler, a dry powder inhaler, an aerosol generator, and the like. In another embodiment, the O₂* composition is administered via pressurized intraperitoneal aerosol therapy, such as pressurized intraperitoneal aerosol chemotherapy (PIPAC), or other high-pressure aerosolizing means. In other embodiments, the O₂* composition is delivered orally, intravenously, subcutaneously, or via installation into a cavity, such as intraperitoneal, intravesical, intravitreal, intraarticular, and the like. In one embodiment, a stent may be charged with the O₂* composition and delivered intravascularly or intralymphatically. In another embodiments, the O₂* composition is delivered via intra-arterial needle-free injection.

In one embodiment, the biological molecule to which the label is affixed is an antigen-binding protein, such as an antibody, antibody fragment (e.g., Fab), soluble receptor, receptor fusion protein, receptor-Fc-fusion protein or trap molecule, and the like. For example, the biological molecule can be a monoclonal antibody that specifically binds a tumor antigen, an extra-cellular matrix protein, a stroma cell-specific antigen, or a fibroblast-specific antigen. Non-limiting examples of useful antibodies include anti-EGF receptor antibodies (e.g., cetuximab) for cancer, and anti-LOXL2 (e.g., simtuzumab) for fibrosis. (LOXL is involved in the cross-linking of collagen and elastin.) Examples of Fc-fusion proteins include the VEGF antagonist aflibercept, the inerleukin-1 antagonist rilonacept and the TNF antagonist etanercept.

In some embodiments, the biological molecule comprises a soluble receptor fragment or a ligand that binds to a cell surface receptor. For example, the biological molecule may comprise the Arg-Gly-Asp tripeptide motif (RGD) of fibronectin that binds integrin. A labeled RGD-containing polypeptide will bind those cells that express integrins. Integrins are transmembrane receptors involved in cell-cell and cell-extracellular matrix (ECM) interactions. Integrins mediate fibroblast to ECM interaction and are important in tumor stromal cell integrity. Thus, those molecules having an RGD motif bind to cancer stromal tissue (i.e., fibroblast cells), making them an important tumor targeting moiety.

In some embodiments, the biological molecule is a small molecule that interacts with biological systems. For example, tyrosine kinase inhibitors are biological molecules since they bind to cell signaling molecules in a cell, and affect cell signaling and cell proliferation. Useful tyrosine kinase inhibitors that can be labeled and used in the O₂* composition include inter alia afatinib, axitinib, bafetinib, bosutinib, cediranib (Recentin), crizotinib, dasatinib (Sprycel), erlotinib hydrochloride (Tarceva), gefitinib (Iressa), imatinib (Gleevec, Glivec), lapatinib (Tykerb/Tyverb), lestaurtinib, neratinib, nilotinib (Tasigna), nintedanib, ponatinib, quizartinib, regorafenib, ruxolitinib, sunitibin (Sutent), tofacitinib, vandetanib (Zactima), N-acetylcysteine, and vatalanib.

The biological molecule of the O₂* composition comprises a label. In some embodiments, the label is covalently linked to the biological molecule. In some embodiments, the label is a fluorescent molecule that is excited by EMR at a first wavelength, and emits EMR at a second wavelength. Useful fluorescent labels include photosensitizers, quantum dots, lanthanide series chelates (e.g., terbium, europium), fluorescein derivatives, rhodamine derivatives, coumarin derivatives, cyanine derivatives, near infra-red probes, including for example IRDye® 800CW, IRDye® 700DX, IRDye® 680LT, and IRDye® 680RD (LI-COR, Inc., Lincoln, Nebr.).

A laser that emits EMR at the excitation wavelength of the dye is selected and applied to the target area. The dye absorbs the light, and emits light of a lower wavelength. Thus, in some embodiments where the biological molecule is labeled with IRDye® 700DX or IRDye® 800CW, the laser emits light in the near IR (i.e., about 700 nm or 800 nm) to excite the labeled target and create cell-damaging emission light.

A. Photoimmunotherapy (PIT) Compositions

The invention provides a method of killing or removing a tumor containing stromal and cancer cells is provided. In one embodiment, the method includes contacting a tumor or other cells or tissue with a combination of a fluorescently labeled anti-cancer drug with a perfluorocarbon emulsion that significantly enhances the photodynamic tumor-killing power of the labeled drug. In one embodiment, the labeled drug is a labeled tyrosine kinase inhibitor, such as a labeled nintedanib. In some embodiments, the labeled drug is monoclonal antibody conjugated with a near infrared dye, such as IR700 (mAb-IR700). It is generally known in the art that mAb-IR700 is an effective anti-cancer medicament when used in photoimmunotherapy (PIT). Mitsunaga et al., for example describes the effectiveness of trastuzumab-IR700 and panitumumab-IR700 PIT in killing HER2-expressing 3T3 cells. Here, the combination of the mAb-IR700 with perflubron emulsion significantly improves the PIT killing effect of mAb-IR700 by ≥10%, ≥15%, ≥20%, ≥25%, ≥30%, ≥35%, ≥40%, ≥45%, ≥50%, ≥55%, ≥60%, ≥65%, ≥70%, ≥75%, ≥80%, ≥85%, ≥90%, ≥95%, ≥100%, ≥150%, ≥200%, ≥4-fold, ≥5-fold, ≥6-fold, ≥7-fold, ≥8-fold, ≥9-fold, ≥10-fold, ≥15-fold, ≥20-fold, ≥25-fold, ≥50-fold, ≥75-fold, or ≥100-fold over the mAb-IR700 in the absence of perflubron emulsion.

In some embodiments, the near infrared fluorescent label has an absorbance maximum at any wavelength along the near infrared section of the EMR spectrum. In some embodiments, near infrared (NIR) includes EMR with a wavelength of about 700 nm to about 1400 nm. While IR700 dyes have been shown to have some efficacy in PIT cancer cell killing, IR800 has heretofore not been shown to be effective in PIT. The inventor has discovered that the combination of mAb-IR800 with a perfluorocarbon emulsion is effective as a PIT composition to kill tumors. This provides several advantages of traditional IR700 PIT, one of which is the deeper tissue penetration of 800 nm light into tissues and the concomitant improved tumor background ratio (TBR), another is the increased availability in medical facilities and lower cost of 800 nm lasers and cameras over 700 nm systems.

While not wishing to be bound by theory, the improved effectiveness of the perfluorocarbon plus mAb-IR700 or mAb-IR800 composition over the mAb-IR700 or mAb-IR800 composition without the perfluorocarbon, may be due in part inter alia to (1) the improved oxygen delivery by the perfluorocarbon to the site of PDT, thereby enhancing sustained generation of reactive oxygen species, and/or (2) the killing effect of perfluorocarbon formulations on tumor stromal cells and other peri-tumoral fibroblasts and macrophages.

In one embodiment, a composition comprising a biological molecule-near infrared fluorophore conjugate (NIR-C) and a perfluorocarbon emulsion is provided. In one embodiment, the biological molecule is an antibody or an antibody fragment, such as a Fab. In one embodiment, the biological molecule is a monovalent monospecific antibody or fragment thereof. In another embodiment, the biological molecule is a bivalent monospecific antibody or fragment thereof. In another embodiment, the biological molecule is a bivalent bispecific antibody or fragment thereof, or other multispecific antigen-binding protein. In another embodiment, the biological molecule is an immunoadhesin (Ashkenazi and Chamow, Methods, 8(2): 104-115, 1995) or other receptor Fc-fusion protein or trap molecule.

In a specific embodiment, the antibody is cetuximab or an antibody-drug conjugate thereof. In a more specific embodiment, the NIR-C is cetuximab-IRDye® 700DX. In another specific embodiment, the NIR-C is cetuximab-IRDye® 800CW.

The perfluorocarbon and NIR—C are combined in various proportions according to the particular application. In one embodiment, the weight-to-weight ratio of perfluorocarbon to NIR-C(perfluorocarbon/NIR-C) is about 0.5-2000, 1-1000, 10-500, 50-500, 200-700, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, 200, 300, 400, 500, 600, 700, 800, 900, 1000, 1200, 1400, 1600, 1800, 2000, or >2000. Preferred weight-to-weight ratios of perfluorocarbon to NIR-C(perfluorocarbon/NIR-C) include 100, 150, 200, 250, 300, 350, 400, 450, 500, 550, and 600. In a preferred embodiment, the weight-to-weight ratio of perfluorocarbon to NIR-C(perfluorocarbon/NIR-C) is 300±45 or 150±23.

In some embodiments, the perfluorocarbon is formulated in a first part and the NIR-C is formulated in a second part, and then the first and second parts are combined to form the perfluorocarbon/NIR-C combination. In one embodiment, the perfluorocarbon-containing first part contains ≥10%, ≥20%, ≥30%, ≥40%, ≥50%, ≥60%, ≥70%, ≥80%, ≥90%, 100%, 50%-100%, 50%-90%, 50%-80%, 50%-70%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99% or 100% perfluorocarbon.

In some embodiments, the perfluorocarbon-containing first part also contains an emulsifier, such as, e.g., egg yolk phospholipid and/or lecithin. In one embodiment, the perfluorocarbon-containing first part contains ≤1%, ≤2%, ≤3%, ≤4%, ≤5%, ≤6%, ≤7%, ≤8%, ≤9%, ≤10%, ≤15%, ≤20%, ≤25%, ≤30%, ≤35%, ≤40%, ≤45%, or ≤50% emulsifier. In a preferred embodiment, the perfluorocarbon-containing first part contains 60% perfluorocarbon and 40% emulsifier.

In some embodiments, the NIR-C-containing second part contains about 0.5-200 mg/mL, 1-100 mg/mL, 10-100 mg/mL, 20-200 mg/mL, 1 mg/mL, 2 mg/mL, 5 mg/mL, 10 mg/mL, 15 mg/mL, 20 mg/mL, 25 mg/mL, 30 mg/mL, 35 mg/mL, 40 mg/mL, 45 mg/mL, 50 mg/mL, 55 mg/mL, 60 mg/mL, 65 mg/mL, 70 mg/mL, 75 mg/mL, 80 mg/mL, 85 mg/mL, 90 mg/mL, 95 mg/mL, 100 mg/mL, 110 mg/mL, 120 mg/mL, 130 mg/mL, 140 mg/mL, 150 mg/mL, 160 mg/mL, 170 mg/mL, 180 mg/mL, 190 mg/mL, 200 mg/mL, or 250 mg/mL NIR-C. A preferred NIR-C-containing part contains about 2 mg/mL NIR-C.

In some embodiments, the perfluorocarbon-containing part is combined with a diluent prior to or concomitantly with combining with the NIR-C-containing part. In one embodiment, the diluent is a buffered aqueous solution, such as phosphate-buffered saline (PBS). In one embodiment, the perfluorocarbon-containing part (pen) is combined with the diluent in a volume-to-volume ratio (perf:diluent) of 100:0, 95:5, 90:10, 80:20, 75:25, 70:30, 65:35, 60:40, 55:45, 50:50, 45:55, 40:60, 35:65, 30:70, 25:75, 20:80, 10:90, or 5:95 to form a diluted perfluorocarbon-containing part (dilperf).

In one embodiment, the subject diluted perfluorocarbon-containing part (dilperf) is combined with the NIR-C-containing part (nirc) in a volume-to-volume ratio (dilperf:nirc) of 95:5, 90:10, 80:20, 75:25, 70:30, 65:35, 60:40, 55:45, 50:50, 45:55, 40:60, 35:65, 30:70, 25:75, 20:80, 10:90, or 5:95 to form the perfluorocarbon-NIR-C combination PIRC). For the sake of clarity, a 50:50 dilperf:nirc ratio in some case may represent for example 25:25:50 perf:diluent:nirc, 20:30:50 perf:diluent:nirc, et cetera. In a preferred embodiment, the perfluorocarbon-containing part is combined with diluent at a volume to volume ratio of 50:50, and the diluted perfluorocarbon containing part is then combined with the NIR-C-containing part at a volume to volume ratio of 50:50. Preferably a perfluorocarbon emulsion containing 60% (w/v) perfluorocarbon and 40% (w/v) emulsion is combined 50:50 with a diluent such as PBS, and then combined with an NIR—C containing about 2 mg/mL of the biological molecule, to form a combination (i.e., PIRC) containing 30% (w/v) perfluorocarbon, 20% (w/v) emulsion, 1 mg/mL biological molecule. A preferred biological molecule is an anti-cancer monoclonal antibody, such as cetuximab, linked to an IR700 or IR800 fluorophore.

B. Use of Photoimmunotherapy Compositions

In one embodiment, (1) the PIRC is administered to a patient (human subject or animal) intravenously, (2) the tumor is imaged, and (3) the tumor is biopsied, removed or otherwise disturbed. In one embodiment, the tumor is subjected to photodynamic therapy at or near the time of imaging. In a preferred embodiment, the tumor is subjected to photodynamic therapy prior to disturbing the tumor. In one embodiment, the patient is subjected to further cancer treatment such as surgery, radiation therapy, and/or chemotherapy.

In one embodiment, the patient is administered a therapeutically effective amount of oxygen prior to imaging, PDT or otherwise disturbing the tumor. The amount of oxygen delivered to the patient is selected to optimize the amount of oxygen surrounding the tumor to enhance the sustained production of reactive oxygen species at the tumor site during and after photodynamic therapy. While not wishing to be bound by theory, sustained delivery of an amount of oxygen to a patient may over time lead to vasoconstriction and consequent reduction of oxygen to the tumor site. Therefore, the practitioner of ordinary skill in the art can adjust the amount and timing of oxygen delivery to the patient to deliver optimal amounts of oxygen to the tumor for sustained effective PDT.

In one embodiment, the patient is administered an amount of oxygen 2-5 minutes, 10 minutes, 9 minutes, 8 minutes, 7 minutes, 6 minutes, 5 minutes, 4 minutes, 3 minutes, 2 minutes, 1 minute, or less than 1 minute prior to delivery of the PDT light to the tumor. In one embodiment, the amount of oxygen delivered to the patient's lungs is ≥21 kPa, 25-101 kPa, 25 kPa, 30 kPa, 35 kPa, 40 kPa, 45 kPa, 50 kPa, 55 kPa, 60 kPa, 65 kPa, 70 kPa, 75 kPa, 80 kPa, 85 kPa, 90 kPa, 95 kPa, or 101 kPa.

In one embodiment, (1) the PIRC is administered to the patient about 1 minute to 8 hours, 8 hours, 16 hours, 24 hours, 32 hours, 40 hours, 48 hours, 3 days, 4 days, 5 days, 6 days, or 7 days prior to (2) imaging or applying light for PDT prior to or concomitantly with biopsy or resection of the tumor. In one embodiment, PDT is applied immediately upon the topical application of the PIRC. In one embodiment, the PDT light (e.g., laser or other light source tuned to the subject fluorophore) is administered to the tumor at a dose of 20-50 J/cm², 40-500 J/cm², ≥50 J/cm², 50-75 J/cm², 40-120 J/cm², 70-260 J/cm², 20 J/cm², 30 J/cm², 40 J/cm², 50 J/cm², 60 J/cm², 70 J/cm², 80 J/cm², 90 J/cm², 100 J/cm², 110 J/cm², 120 J/cm², 130 J/cm², 140 J/cm², 150 J/cm², 160 J/cm², 170 J/cm², 180 J/cm², 190 J/cm², 200 J/cm², 220 J/cm², 240 J/cm², 260 J/cm², 280 J/cm², 300 J/cm², 350 J/cm², 400 J/cm², 450 J/cm², or 500 J/cm².

In one embodiment, the therapeutic light is delivered inter alia by a laser, a non-laser light source (e.g., diode, incandescent, halogen, fluorescent, mercury vapor, and the like), an over-the-shoulder light source, or a fiber optic line positioned in, at or near the tumor.

In another embodiment, (1) the PIRC is administered peritumorally or intratumorally, (2) the tumor is imaged, and (3) the tumor is biopsied, removed or otherwise disturbed. In one embodiment, the tumor is subjected to photodynamic therapy at or near the time of imaging and prior to disturbing the tumor. In one embodiment, the patient is subjected to further cancer treatment such as surgery, radiation therapy, and/or chemotherapy. Here, a therapeutically effective amount of oxygen is delivered to the tumor or combined with the PIRC prior to or during peritumoral administration to promote ROS formation during PDT.

In one embodiment, after the PIRC is administered around the tumor, the PIRC is allowed to diffuse into the lymph vessels and sentinel lymph node. The lymphatic system proximal to the tumor is then mapped by following the fluorescent signal. The lymph channel and nodes are then subjected to PDT before to, during, and/or after the tumor is biopsied, excised, or otherwise disturbed. Administration of light to the lymph system and other areas proximal to the tumor post-disturbance is called “surgical sterilization” since it kills tumor cells that moved from the tumor into the surrounding tissues during disturbance (tumor cell spread) and proximal microtumors. In one embodiment, an intravenous laser fiber is placed proximal to the tumor and illuminated immediately prior to biopsy to kill any escaping tumor cells that contain photosensitizer.

In some embodiments, after the surgeon removes tumor and lymph nodes, intraoperative x-ray, fluoroscopy, CT, MRI, or other imaging methods can be used to identify any perfluorocarbon, which indicates the presence of residual tumor cells, to enable the surgeon to verify that all lymphatic channels and lymph nodes have been removed. Surgical oncologists often try to blindly remove every node possible after surgery, but this can be challenging.

Non-limiting examples of cancer/tumors that can be treated by both intravenous and peritumoral/intratumoral PIRC administration include inter alia melanomas and other skin cancers, bladder cancers, breast cancers, head and neck cancers, pancreas cancers, and lung cancers.

In another embodiment where the tumor is mucosal, cutaneous, subcutaneous, or at or near the surface of the skin, (1) the PIRC or perfluorocarbon formulation is applied to the surface of the skin, and (2) the tumor is imaged with probe confocal laser endomicroscopy confocal microscopy prior to biopsy, excision, or other disturbance of the tumor and subsequent surgical sterilization.

C. Improved visualization of mucosa

In one embodiment, perfluorocarbon or perfluorocarbon emulsion (e.g., perflubron) is washed over the surface of the skin or mucosa to facilitate removal of mucus and to further smooth the surface of the mucosa to enable better contact and smoother laser delivery and retrieval of Raman spectra wavelengths for cancer detection and cancer cell ablation. In a specific embodiment, the mucosal surface is of the esophagus and the perfluorocarbon is pushed down, where it removes the mucus enables the endoscopist to more clearly visualize color changes in the lower esophagus associated with Barrett's esophagus (or other dysplasias). The color change is associated with dysplasia in the layer. In one embodiment, the perfluorocarbon increases the sensitivity and specificity of detection of dysplasia by ≥20%, ≥30%, ≥40%, ≥50%, ≥60%, ≥70%, ≥80%, ≥90%, or ≥100% over traditional methods, such as the administration of N-acetylcysteine (NAC) alone as a surface preparation. In one embodiment, the perfluorocarbon is administered along with NAC.

D. Pretreatment of lymphatic channels, lymph nodes, and other suspect tissue prior to resection

The manipulation of tissue containing or suspected of containing cancer or pre-cancer cells increases the risk of mobilizing transformed cells that may colonize a distal area. Here, a suspect tissue is injected or otherwise contacted with the O₂* composition and subjected to laser treatment. For example, in one embodiment, a patient with a low rectal cancer has his tumor injected (or peritumoral application) with a composition comprising oxygenated perflurbron and cetuximab labeled with IRDye® 700DX. Then, using robotic surgery (e.g., Da Vinci Robotic surgery, Intuitive Surgical, Inc., Sunnyvale, Calif.), the intraperitoneal space is entered with instruments and the tumor area is treated with the appropriate laser (e.g., i.e., 700 nm or 800 nm excitation) prior to surgical manipulation to reduce recurrent metastasis in the lymph node basin.

Likewise, in one embodiment, in the case of head and neck cancer, the subject area is injected (subcutaneous, intravenous, etc.) with the O₂* composition containing the appropriate labeled biological molecule. The area may then be imaged or treated with a laser or other PDT device prior to manipulation of the suspect tissue by surgical instruments.

In one embodiment, a PIRC is administered to the patient (e.g., intravenous or topical), the target tissue is then surveyed with light of the appropriate wavelength and intensity to detect fluorescing tissue, then a therapeutic amount of light is administered (PDT). In one embodiment, perflubron (emulsion)-panitumumab-IRDye800 (“PF PAN 800”) is administered to diagnose cancer (a fluorescent+indicates cancer and because it fluoresces makes it a candidate for PDT), then therapeutic light is administered to kill the tumor and tumor stroma.

In one embodiment, an antigen-specific monoclonal antibody or TKI that is approved and licensed in at least one jurisdiction as an anticancer drug is administered by an approved route (e.g., intravenous, subcutaneous topical, oral, intratumoral, and the like), either contemporaneous with, prior to, or after administration of a fluorocarbon, followed with PDT prior to biopsy. While not wishing to be bound by theory, if cells or collection of cells, and/or tumor exosomes containing stromal elements escape at or shortly after biopsy and after PDT, it is expected that the risk of metastasis will be eliminated or significantly reduced.

Following PF PAN 800 the primary, lymphatic channels and lymph nodes wherever possible will be treated prior to resection and then once removed the area will be “sterilized” by PDT (Lymphatic channels are frequently hard to find but fluoroscopy, x-ray, CT and MM can be used to find them and treat with PDT before removal-see next below)

E. Interstitial pulmonary fibrosis (IPF)

IPF may be imaged and/or treated as described above. In one embodiment, subject lungs are aerosolized daily with 10 ml of an O₂* composition using a device such as e.g., an Aeroneb® Pro (Aerogen, Inc., Deerfield, Ill.) or PAM nebulizer (PAM, Midlothian, VA). Here, the O₂* composition contains a monoclonal antibody (e.g., simtuzumab), a small molecule (e.g., a TKI such as nintedanib), a ligand-containing polypeptide (e.g., an RGD-containing peptide or other integrin-binding moiety), or a like biological molecule that targets myofibroblasts—attached with a label (e.g., IRDye® 700DX or IRDye® 800CW). The tissue is then imaged, or lasered with a 700 nm or 800 nm laser as in PDT. Here, the oxygen charged fluorochemical provides an oxygen-rich microenvironment to support extensive ROS generation and concomitant cell killing.

In one embodiment, imaging can be performed with CT, MRI (which can see perfluorocarbon emulsion), near infrared detection (e.g., using Multispectral optoacoustic imaging [MSOT] or the like) and/or Raman spectroscopy. Laser treatment can be performed via bronchoscopy for example once per week for 3 weeks by using an endoscopic device capable of delivering near infrared wavelength to stimulate for photodynamic killing of the target cells (e.g., cancer cells, tumor associated macrophages and tumor associated myofibroblasts).

F. Melanoma and Non-melanoma

Melanoma or other skin or subcutaneous cancer (e.g., basal cell carcinoma) may be imaged and/or treated similarly. Using topical application, an injection device, or a needle free injection device, an O₂* composition can be delivered to the integument, oral cavity or trunk or extremity. Here, the O₂* composition contains a monoclonal antibody (e.g., simtuzumab, bevasizumab, cetuximab), a small molecule (e.g., a TKI such as nintedanib), a ligand-containing polypeptide (e.g., an RGD-containing peptide or other integrin-binding moiety), or a like biological molecule that targets the tumor cells or its supporting stroma—attached with a label (e.g., IRDye® 700DX or IRDye® 800CW). The tissue is then imaged, or lasered with a 700 nm or 800 nm laser as in PDT. Here, the oxygen charged fluorochemical provides an oxygen-rich microenvironment to enhance diagnostic imaging and support extensive ROS generation and concomitant cell killing. In some embodiments, diagnostic imaging for melanoma includes Raman spectroscopy, which can be used as a screen for melanoma when coupled with probe confocal laser endomicroscopy for “bloodless diagnosis”.

In another embodiment, the melanoma is injected peritumorally with the O₂* composition containing a monoclonal antibody (e.g., simtuzumab), a small molecule (e.g., a TKI such as nintedanib), a ligand-containing polypeptide (e.g., an RGD-containing peptide or other integrin-binding moiety), or a like biological molecule that targets the tumor cells or its supporting stroma—attached with a label (e.g., IRDye® 700DX or IRDye® 800CW). The tissue is then imaged using MSOT or other NIR unit. The tissue is then lasered using a percutaneous unit or laser fibers emitting EMR at 700 nm or 800 nm prior to tissue removal. This procedure is expected to reduce or eliminate metastatic melanoma in the lymphatic channels (i.e., “melanoma in transition”).

In another embodiment, the photosensitizer-perflubron combination is given intravenously or topically to treat nonmelanoma skin cancer. Before and after removal of the lesion, PDT is performed with, e.g., Mohs surgery (see Gross et al., (1999). Mohs Surgery: Fundamentals and Techniques. Saint Louis: Mosby. pp. 248-60. ISBN 978-0-323-00012-3). In one embodiment, after tissue-slice removal fluorescence is performed ex vivo to aid in identification of both tumor and stroma to expedite Mohs evaluation. Perfluorocarbon with or without emulsion can be visualized by Raman SRS, OCT, or other imaging and fluorescence ex vivo. In one embodiment, a fluorophore such as GFP is added post resection to facilitate determination of completeness of tumor resection. Peritumoral injection may also be used to locate and evaluate nearby lymphatics.

In another embodiment, the fluorocarbon (e.g., perflubron; neat, emulsion, with or without oxygen pre-charging) is topically applied to the lesion or suspect area of the skin, followed by topical application of the photosensitizer (e.g., HAL or verteporfin), followed by lasering or other PDT. In another embodiment, the photosensitizer (e.g., HAL or verteporfin) is topically applied to the lesion or suspect area of the skin, followed by topical application of the fluorocarbon (e.g., perflubron; neat, emulsion, with or without oxygen pre-charging), followed by lasering or other PDT. In yet another embodiment, the photosensitizer (e.g., HAL or verteporfin) and the fluorocarbon (e.g., perflubron; neat, emulsion, with or without oxygen pre-charging) are concurrently topically applied to the lesion or suspect area of the skin, followed by lasering or other PDT.

In some embodiments, the photosensitizer is topically administered at a rate or concentration of about 0.1 mg/m²-100 mg/m², about 1 mg/m²-20 mg/m², about 1 mg/m²-10 mg/m², about 0.1 mg/m², about 0.2 mg/m², about 0.3 mg/m², about 0.4 mg/m², about 0.5 mg/m², about 0.6 mg/m², about 0.7 mg/m², about 0.8 mg/m², about 0.9 mg/m², about 1 mg/m², about 2 mg/m², about 3 mg/m², about 4 mg/m², about 5 mg/m², about 6 mg/m², about 7 mg/m², about 8 mg/m², about 9 mg/m², about 10 mg/m², about 11 mg/m², about 12 mg/m², about 13 mg/m², about 13.2 mg/m², about 13.5 mg/m², or about 13.8 mg/m². In one embodiment, the photosensitizer is topically administered at a rate or concentration of <14 mg/m².

G. Hepatic Fibrosis

In other embodiments, the method applies to the imaging and treatment of other fibroses, such as nonalcoholic fatty liver disease (Nonalcoholic Steatohepatitis or NASH), cirrhosis, or other hepatic fibroses, and bile duct fibrosis such as primary sclerosing cholangitis. Here, the O₂* composition is delivered via the portal vein, intravenous or intrahepatic. Photodynamic therapy can be delivered in e.g., 3 to 5 days

H. IR guided laser prior to biopsy

In one embodiment, the method is incorporated in the biopsy step. Here, a patient with a mass (e.g., a mass in the neck) is injected with an O₂* composition (oxygenated fluorocarbon emulsion plus labeled biological molecule specific for the target cancer). The interventional radiologist (IR) advances the biopsy needle toward the mass, and as the needle approaches or contacts the surface of the suspect mass a laser that is incorporated into the needle device is fired and kills the cells about to be biopsied. This procedure is expected to help ensure that any cancer cells that may be ejected by insertion of the needle are dead. A similar procedure can be employed intra-abdominally for example, or other similar situations.

In one embodiment, IR guidance is used to treat lymphatic channels and, in some instances, deep tumors by traversing the vasculature proximal to masses or lymph nodes. Here, a laser fiber is used intravascularly to impact the vessel-proximal tumor and lymphatic metastasis (i.e., so called “cancer in transition”).

I. Coronary Artery Blockage

In one embodiment, a patient with severe multiple coronary artery blockages that is not amenable to insertion sequential stents is administered the O₂* composition, and subsequently subjected to PDT (e.g., 3 days later) by heart catheter using PDT fiber. Alternatively, a stent is enriched with the photosensitizer and subsequently delivered via PDT fiber or an external source such as e.g., conventional radiation. In some embodiments, dissolvable stents are used.

J. Imaging Methods and Scope-Based Treatment

Perflubron (PFOB) and perflubron emulsion (PFCE) and their gas-based properties enable improved imaging and screening of a variety of areas for cancer within the human or animal subject. Non-limiting examples of newer imaging modalities that can be enhanced with PFOB/PFCE include Optical Coherence Topography (OCT), Narrow Band Imaging (NBI), Raman spectroscopy such as Surface-Enhanced Raman Spectral Scattering (SERS). See Podoleanu, “Optical coherence tomography,” The British Journal of Radiology, 78(935), 2014; Hamamoto et al., “Usefulness of narrow-band imaging endoscopy for diagnosis of Barrett's esophagus,” Journal of Gastroenterology, January 2004, Volume 39, Issue 1, pp 14-20; and Qian et al., “In vivo tumor targeting and spectroscopic detection with surface-enhanced Raman nanoparticle tags,” Nature Biotechnology 26, 83-90 (2008), for describing OCT, NBI and Raman spectroscopy or SERS, respectively.

PFOB/PFCE and other perfluorocarbons and emulsions are contemplated to be superior tumor imaging agents than those agents that are currently in use. The perflurocarbons or their emulsions also enable the viewing of the effects of treatment to enable improved outcomes for patients. In some embodiments, the visualization of tumors or other transformed or pre-cancerous cells with PFOB/PFCE by OCT and NBI is followed by gas-based treatment such as photodynamic therapy (PDT) and subsequent resection of the tumor or other transformed cells.

In some embodiments, Raman spectroscopy, stimulated Raman spectroscopy (SRS), or surface-enhance Raman spectroscopy (SERS) is used to clearly and rapidly identify the carbon-fluorine (C-F) bonds. C—F bonds have a Raman emission signature that indicates the location of the perflurocarbon molecules. In some embodiments, a colonoscope or other endoscope such as bronchoscope, cystoscope and upper gastrointestinal endoscope incorporates Raman spectroscopy or SRS to identify the PFOB/PFCE to enable gas based therapy. In some embodiments, commercial instruments such as the Verisante AURA™ (Veritante Technology, Inc., Richmond, BC) or i-RAMAN® (B&W Tek, Newark, Del.) handheld Raman spectroscopy devices or other scopes are used.

In some embodiments, a PFOB/PFCE is delivered to a patient, e.g., per os for the GI tract, or instilled or aerosolized into, e.g., the GI tract, lungs, bladder, or peritoneal cavity. The target is then probed (e.g., 0.05-24 hours later) with a Raman spectroscopy or SRS probe to identify possible cancer cells.

PFOB/PFCE targets and perfuses fibroblasts and macrophages, and concentrates near tumors. In some embodiments, a Raman spectroscopy or SERS probe is used to “excite” the C-F bonds of the perfluorocarbon molecules with a laser and generate a characteristic signal. C—F bonds are generally not found in humans, therefore when the probe identifies the C-F signal it identifies the location of the PFOB/PFCE product. When the C-F bond is detected, then the concomitantly added fluorescent dye such as ICG, IRDye, or other fluorescent combinations such as fluorescein, green fluorescent protein, and the like, is delivered. A second imaging modality such as probe confocal laser endomicroscopy (pCLE) is then used to confirm that the signal is generated from a cancer as opposed to an infection that recruits macrophages and generates a non-cancer C-F signal. Regardless of the potential to initially detect non-cancer signals, the sensitivity of Raman spectroscopy and the SRS will enable fewer cancer lesions to be missed by the physician whether on skin or intraluminal (e.g. oral cavity, esophagus, stomach, colon, bladder or peritoneum).

One of the major problems currently associated with image guided surgery is the undefined edges of a tumor (“fuzzy” outline of the tumor) making clean resection of the tumor difficult for the surgeon Raman spectroscopy can be used to identify C-F bonds after IRDye administration to visualize the well-marked edges of the tumor to enable more complete removal of the tumor. Thus in one embodiment, Raman spectroscopy is used to identify or assist in identifying the tumor edge for resection.

In some embodiments, once cancer or tissues or cells-of-interest are identified by non-invasive means, gas-based treatment of the lesion prior to biopsy can be performed and the lesion removed. In some embodiments, if cancer is suspected as negative pCLE, then PDT and biopsy can be subsequently performed.

K. Treatment of Eye Diseases and Intraocular/Intravitreal Administration

In one aspect, the invention provides pharmaceutical composition for administration to the eye. In one embodiment, the pharmaceutical composition contains perflubron and an anti-angiogenic medicament. The antiangiogenic medicaments can be small molecules (organic molecules <900 Daltons) or large molecules. The large molecule can be for example a polyclonal antibody, a monoclonal antibody, an antibody fragment such as a F(ab′)2 fragment or a Fab′ fragment, a trap molecule or other immunoadhesin or receptor-Fc fusion protein, a receptor fusion protein, a nucleic acid molecule, or an aptamer. Useful antiangiogenic medicaments include for example aflibercept (VEGF-Trap), ranibizumab, pegaptanib, bevacizumab, verteporfin, certolizumab, fomivirsen, and the like.

In another aspect, the invention provides a method for treating an eye disease by administering a pharmaceutical composition containing perflubron and an anti-angiogenic medicament. In some embodiments, the eye disease is macular degeneration, wet AMD, macular edema due to retinal vein occlusion, diabetic macular edema, diabetic retinopathy, and the like. In one embodiment, the pharmaceutical composition is administered intravitreally.

In a specific embodiment, the pharmaceutical composition contains perflubron, aflibercept, and optionally another excipient, in a vial or in a pre-filled syringe for intravitreal administration.

L. Enhanced photosensitizer activity and oxygen delivery for photodynamic therapy

In one aspect, the invention provides a system for killing tumor cells, both tumor cancer cells and tumor stroma cells, wherein the system isolates the tumor and the tumor killing composition from the ambient environment. In one embodiment, the system contains a cap-like container positioned at or near the distal end of a viewing scope or optical waveguide and open on one end to accommodate a tumor. In one embodiment, the container (also referred herein as “cap”) contains a perfluorocarbon, molecular oxygen, and a photosensitizer. While not wishing to be bound by theory, the cap-like container isolates the oxygen-charged perfluorocarbon and photosensitizer from the gaseous environment of the tissue and surrounding tissue environment, to prevent the unintended diffusion of oxygen from the targeted tumor, and the unintended diffusion of carbon dioxide and/or other gases into the target area. Carbon dioxide is generally used in surgery and tumor ablation practice to inflate lumens such as the bladder lumen or colon lumen to enable visualization and manipulation. Carbon dioxide is well-known to displace oxygen in perfluorocarbon formulations. This cap-like container prevents oxygen loss or reduction of oxygen concentration at the site of photodynamic therapy, enabling long term oxygen delivery to tissues for the generation of cell-killing reactive oxygen species.

In one embodiment, the cap-like container is a sealed ablation cap. See U.S. Pat. No. US20020183739A1, which is herein incorporated for teaching a sealed ablation cap placed at the distal end of a flexible endoscope. In one embodiment, the cap is positioned at or near the distal end of an endoscope through which the perfluorocarbon, oxygen, and photosensitizer can be delivered into the cap and eventually onto or into the target tissue.

In one embodiment, the perfluorocarbon, oxygen, and photosensitizer (PerOxPho) are combined prior to delivering the PerOxPho combination to the target tissue. Here, the perfluorocarbon, which can be neat or in an emulsion, is saturated with oxygen (O₂). In another embodiment, the one or more of the perfluorocarbon, oxygen, and/or photosensitizer (optionally with quencher) are delivered separately to the tumor/tissue and combined at the point of delivery. In one embodiment, the perfluorocarbon, oxygen, and photosensitizer (optionally with quencher) are delivered into a cap covering the tumor and preventing the outgassing of oxygen into the surrounding tissue and/or the in-gassing of CO₂ into the system.

In another embodiment, the perfluorocarbon, oxygen, and photosensitizer are deployed (e.g., administered to the patient) separately and in some cases through different routes of administration. In one embodiment, the perfluorocarbon is directly applied to the target tissue, such as by instillation, intravesical injection, topical application, or the like; the photosensitizer is administered intravenously at a site remote from or near to the target, via intravesical injection, or topical application to the target tissue; and the oxygen may be administered via the patient airway, aspirated into the lumen of an organ or area surrounding the target, or through a scope directly onto the target. Each of these components may be delivered at different times and sequences. In one embodiment, the perfluorocarbon can be delivered several days before the oxygen or photosensitizer is delivered. In one embodiment, the photosensitizer is delivered via intravenous injection before administering the perfluorocarbon or oxygen. In one embodiment, the perfluorocarbon and the oxygen are combined (i.e., oxygen-saturated perflubron) and delivered via a scope to the target tissue and the photosensitizer is delivered via intravenous injection. In one embodiment, the perfluorocarbon and the oxygen are combined (i.e., oxygen-saturated perflubron) and delivered via a scope to the target tissue and the photosensitizer is delivered via intravesical injection. In one embodiment, the tumor stroma is loaded with perflubron or perflubron emulsion prior to the administration of the photosensitizer. While not wishing to be bound by theory, it is envisioned that the duration of PDT is much reduced by pre-loading the tumor with the perflubron or emulsion thereof. In one embodiment, the oxygenated perfluorocarbon (or its emulsion) and/or photosensitizer is/are administered per os. In another embodiment, the oxygenated perfluorocarbon (or its emulsion) and/or photosensitizer is/are administered topically. In one embodiment, the oxygenated perfluorocarbon (or its emulsion) and/or photosensitizer is administered intravenously.

In some embodiments, oxygenated perfluorocarbon is deployed as an oral preparation or spray catheter to the target and surrounding area to clear mucous from the target area surface and to enhance the uptake of the perfluorocarbon (or PerOxPho) into the target stroma.

In one embodiment, the photosensitizer is a fluorescent molecule. In some embodiments, the photosensitizer has biological activity as well as Type I and/or Type II photochemical activity. In a specific embodiment, the photosensitizer having biological activity is a PKI such as nintedanib or a photosensitizer such as verteporfin. In other embodiments, the photosensitizer is combined with or linked to a biologically active molecule such as an antibody or antibody fragment (e.g., LUCENTIS), an aptamer (e.g., MACUGEN), a fusion protein (e.g., aflibercept), or a small molecule (<900 Daltons) drug (e.g., nintedanib). In one embodiment, the photosensitizer is aminolevulinic acid (5-ALA), hexaminolevulinate (HAL), talaporfin (Laserphyrin) (TAL), porfimer sodium (Photofrin), a benzoporphyrin derivative (verteporfin), a canonical fluorophore such IR700, IR800, rhodamine and derivatives, fluorescein and derivatives, and the like, a molecule that is generally not regarded as canonical fluorophores or photosensitizers, but absorbs higher energy radiation and emit lower energy radiation, such as for example nintedanib, which exhibits fluorescent properties, or the like.

In one embodiment, verteporfin is the preferred photosensitizer that is combined with the perfluorocarbon without the need to add an aqueous solvent to form an emulsion. Verteporfin is provided as a lyophilized emulsion, such that when perflubron is used as the mixing agent instead of water, an emulsion of perflubron and a potent PDT agent is formed. Furthermore, verteporfin is known in the art to have inhibitory action on cancer cells without light activation. In a specific embodiment, the PhoOxPher composition contains perflubron added to lyophilized verteporfin emulsion for use for example in 2-photon killing (or other multiphoton wavelength killing application). In another embodiment, the aqueous emulsion contains verteporfin (with its included emulsifiers as a lyophilized emulsion), perflubron, and additional emulsifier(s) to help maintain the resultant emulsion and eliminate or slow-down any phase separation.

In one embodiment, oxygenated perflubron is combined with verteporfin and administered with PDT to a tumor to treat cancer, or a non-tumor to treat non-cancers such as choroidal neovascularization or excessive epidermal blood vessels (i.e., port wine stains). In a specific embodiment, the perflubron-verteporfin combination is administered intravitreal, suprachoroidal, or to the eye by another route to treat choroidal neovascularization (e.g., age related macular degeneration [AMD]) via PDT. In another embodiment, the perflubron-verteporfin combination (combination includes sequential administration of each component in any order, or a mixture of each individual component) is administered topically or to the skin by another route to treat port wine stains via PDT.

In another embodiment, conventional radiation is used to stimulate verteporfin as opposed to using visible, near infrared, or infrared light, which can only travel about 1 cm into the body. Here, given the tissue penetrating power of gamma radiation, the effective depth of the PDT is significantly increased. For example, when using gamma radiation for PDT in the practice of this invention, one would not need a administer a scope down into the lung, which requires anesthesia, but rather simply administer external beam radiation. Xu et al., “Combination of Photodynamic Therapy with Radiotherapy for Cancer Treatment,” Journal of Nanomaterials, Volume 2016, Article ID 8507924 is incorporated herein by references for teaching the combination of PDT with conventional radiotherapy.

In one embodiment, the photosensitizer is or contains a tetrapyrrole such as a porphyrin, which includes for example Photofrin, protoporphyrin IX, 5,10,15,20-tetrakis(1-methylpyridinium-4-yl) porphyrin tosylate, and XF-70. In one embodiment, the photosensitizer is or contains a chlorin, which includes for example Radachlorin, Foscan, Verteporfin, chlorin(e6), monoaspartyl chlorin(e6) (Talaporfin sodium), and HPPH. In one embodiment, the photosensitizer is or contains a bacteriochlorin, which includes for example TOOKAD Soluble (WST-11), LUZ11, BC19, and BC21. In one embodiment, the photosensitizer is or contains a phthalocyanine, which includes for example liposomal ZnPC, chloroaluminium sulfonated phthalocyanine (CASP), Silicon phthalocyanine (PC4), and RLP068. In one embodiment, the photosensitizer is or contains a natural or synthetic dye, including for example phenothiazinium salts, such as methylene blue, toluidine blue 0, and PP904, benzophenothiazinium salts such as EtNBS, halogenated xanthenes such as Rose Bengal, squaraines such as ASQI, boron-dipyrromethene compounds (BODIPYs) such as Zinc(II)-dipicolylamine di-iodo-BODIPY and DIMPy-BODIPY, phenalanones, transition metal complexes such as ruthenium complexes, rhodium complexes, and iridium complexes, and natural compounds such as the perylenequinones hypericin and hypocrellin, flavins such as cationic riboflavin, and curcuminoids such as curcumin. See Abrahamse and Hamblin, “New photosensitizers for photodynamic therapy,” Biochem J. 2016 Feb. 15; 473(4): 347-364, and the references disclosed therein, which are herein incorporated for disclosing photosensitizers that are useful in photodynamic therapy.

In one embodiment, the photosensitizer is Photofrin, which is currently approved by the USFDA for PDT of obstructing (tubes) lungs and esophagus. Photofrin is a mixture of oligomers formed by ether and ester linkages of up to eight porphyrin units. In one embodiment, the Photofrin is injected into a vein of a patient in which oxygen-charged perfluorocarbon had been administered, thereby enabling the rapid uptake of Photofrin into the tumor or cancer cells. 40 hours later, PDT is performed with a shortened time that is less than the standard 12 1/2 to 25 minutes.

In one embodiment, the method of treatment includes that steps of (i) instilling the photosensitizer HAL, (ii) visualizing the HAL with a photodynamic diagnostic (PDD) scope, (iii) instilling the perflubron, and (iv) performing photodynamic therapy (PDT.

While not wishing to be bound by theory, prior to the unexpected discoveries made and disclosed herein, HAL is known in the art as a PDT agent (i) having no cancer PDT killing in hypoxic regions, (ii) having no anti-stromal effects against tumor (i.e., anti-fibroblast activity), (iii) requiring long duration for PDT (i.e., range of 52-100 minutes with a median of about 75 minutes) that consumes local oxygen creating hypoxia compromising PDT effort), (iv) requiring multiple treatments (e.g., three in Phase I—and limited efficacy 23.5% at 9 months and 12% at 21 months [see Bader et al 2013 https://www.ncbi.nlm.nih.gov/pubmed/22440147]). Thus, in one embodiment, HAL is administered to a patient prior to or during PDT using oxygen-saturated perfluorocarbon (e.g., perflubron) with or without a cap. Here, the HAL with or without perflubron may be administered intravesical or intravenous. HAL is currently approved for intravesical administration.

In one embodiment, the PerOxPho combination or individual components thereof contains perflubron saturated with molecular oxygen and any one or more of nintedanib, TAL, HAL, and/or Photofrin.

In some embodiments, the PerOxPho combination is delivered to the tumor through an endoscope, which is equipped with a cap, a resection tool, and laser or other light source to enable tumor removal and photodynamic therapy.

In one embodiment, the PerOxPho combination is delivered to a tumor in an esophagus through an endoscope or like device into a cap that is positioned over the target tissue (e.g., tumor, neoplasia, hyperplasia, dysplasia, carcinoma, sarcoma, and the like). In another embodiment, the photosensitizer is administered to the patient intravenously, followed by delivering the oxygen-saturated perfluorocarbon prior to PDT. In both cases, the esophagus is inflated with a gas, such as CO₂, to provide a surface to resect and ablate the tumor and other tissue as needed. The cap of the PerOxPho-charged cap prevents the inward diffusion of the CO₂ into the perfluorocarbon and the unintended resultant displacement of the oxygen from the perfluorocarbon. By way of example, the esophageal tumor can be a deep invasive esophageal cancer or a less invasive surface esophageal cancer like non-invasive esophageal cancer.

Non-muscle invasive bladder cancer (NMIBC) is a non-life-threatening wart-like tumor that recurs, requiring removal about every 6-months or so. In some cases, the surgeon administers intravesical Bacillus Calmette—Guerin (BCG) vaccine to prevent the recurrence and progression of NMIBC. BCG treatment is not effective in 40% of cases, leading to eventual chemotherapy or bladder removal. In one embodiment to treat NMIBC, a perfluorocarbon emulsion (e.g., perflubron emulsion) is instilled into the bladder for several days prior to endoscopic delivery of the PerOxPho combination. In one embodiment, a PerOxPho is delivered in an emulsion several days prior to scoping. On the day of scoping, the PerOxPho is delivered without emulsifier (to enable clear viewing of the target through the scope) through the scope and into the cap which is encapsulating the target tissue-to-be-ablated. In a specific embodiment, PerOxPho contains nintedanib, and neat perflubron saturated with oxygen. In another specific embodiment, molecular oxygen is delivered to the target, before, during, or after the delivery of the perfluorocarbon (e.g., perflubron) and photosensitizer (e.g., hexaminolevulinate).

V. Definitions

As used herein, “administering” is used in its broadest sense to mean contacting a subject with a composition of the invention.

As used herein, the phrase “metabolic inhibitor” is used in its broadest sense to refer to any bioactive molecule capable of altering at least one metabolic process of a cell. Any metabolic process affecting molecule known in the art or yet to be discovered is contemplated herein. Exemplary metabolic processes include, without limitation, nucleic acid synthesis, amino acid metabolism, protein synthesis, lipid synthesis, glycolysis, mitochondrial metabolism, TCA cycle, fatty acid metabolism, NAD metabolism, phosphoinositide 3-kinase signal transduction, and any other metabolic process relied upon by cancer or pre-cancerous cells.

As used herein, the term “oxygen” includes any one or more molecular forms (molecules, compounds, mixtures). Oxygen can be in the form of an oxygenic molecule such as sodium chlorate, barium peroxide, lithium, sodium, or potassium perchlorate, lithium or sodium chlorate, and the like, a peroxide such as hydrogen peroxide, ozone, elemental oxygen, or other reactive oxygen species, and/or molecular oxygen (i.e., O₂).

The term “perfluorocarbon” is used interchangeably with the term “fluorocarbon.” Perfluorocarbons as used herein include perflubron, other perfluorocarbons (PFC), and perfluorocarbons in neat form (PFC) or as an emulsion (PFCE). The person having ordinary skill in any of the arts of chemistry, biochemistry, pharmacology, medicinal chemistry, and related arts know that different perfluorocarbon species may have different physiological (e.g., effect on fibroblasts, oxygen binding capacity) and physical (e.g., vapor pressure, solubility) properties.

As used herein, the term “photosensitizer” means any molecule that absorbs light. Non-limiting examples of useful photosensitizers are described herein. In some embodiments, the photosensitizer is a fluorescent molecule. In some embodiments, the photosensitizer has biological activity (e.g., nintedanib, which has PKI activity as well as having the ability to undergo Type I and/or Type II photochemical reactions to form reactive oxygen species). All fluorescent molecules are photosensitizers as that term is used herein. Fluorescent molecules and other photosensitizers include those molecules known in the art to be used in conjunction with photodynamic therapy, such as for example aminolevulinic acid (5-ALA), hexaminolevulinate (HAL), talaporfin (Laserphyrin) (TAL), porfimer sodium (Photofrin), a benzoporphyrin derivative (verteporfin), as well as canonical fluorophores such IR700, IR800, rhodamine and derivatives, fluorescein and derivatives, and the like, as well as those molecules that are generally not regarded as canonical fluorophores or photosensitizers, but nonetheless do in fact absorb higher energy radiation and emit lower energy radiation, such as for example nintedanib, which exhibits fluorescent properties.

As used herein, “subject” refers to a living organism having a central nervous system. In particular, subjects include, but are not limited to, human subjects or patients and companion animals. Exemplary companion animals may include domesticated mammals (e.g., dogs, cats, horses), mammals with commercial value (e.g., dairy cows, beef cattle, sporting animals), mammals with scientific values (e.g., captive or free specimens of endangered species), or mammals which otherwise have value. Suitable subjects also include: mice, rats, dogs, cats, ungulates such as cattle, swine, sheep, horses, and goats, lagomorphs such as rabbits and hares, other rodents, and primates such as monkeys, chimps, and apes. In some embodiments, subjects may be diagnosed with a fibroblastic condition, may be at risk for a fibroblastic condition, or may be experiencing a fibroblastic condition. Subjects may be of any age including new born, adolescence, adult, middle age, or elderly.

The terms “target” and “target site” refer to any site that would benefit from receiving the compositions of the present invention. The terms include cells, tissues, aberrant growths, tumors, cancerous lesions, sites of injury, and other sites that may benefit from the compositions of the invention.

The phrase “therapeutic agent” is used herein to refer to any agent that may provide a benefit to a target microenvironment. It is also used to refer to bioactive agents and gaseous substances.

The phrase “therapeutically effective amount” is used herein to mean an amount sufficient to increase to some beneficial degree, preferably to increase by at least about 1 to 100 percent, more preferably by at least about 5 to 95 percent, and more preferably by at least 8 percent or higher, healing or cancer cell death as compared to untreated controls. An “effective amount” is a pharmaceutically-effective amount that is intended to qualify the amount of an agent or compound, that when administered to a subject, will achieve the goal of healing an injury site, increasing cancer cell death, or otherwise benefiting the recipient environment.

As various changes could be made in the above compositions and methods without departing from the scope of the invention, it is intended that all matter contained in the above description and in the Examples given below, shall be interpreted as illustrative and not in a limiting sense.

EXAMPLES

The following examples are simply intended to further illustrate and explain the present invention. The invention, therefore, should not be limited to any of the details in these examples.

Example 1. Treatment of Cancer Cells

The ability of fluorocarbons to dissolve and carry large amounts of gaseous substances makes them a novel anti-cancer therapeutic that may alter the cancer-promoting environment to be less habitable for pre-cancer and cancer cells. To analyze the effectiveness of the combination of fluorocarbons and gaseous substances as an anti-cancer therapeutic, the growth of cancer cells was measured in the presence of fluorocarbon with normal environment (Normoxia) or fluorocarbon with carbon dioxide (Hypoxia).

In particular, two human pancreatic cancer cell lines (Pan02 and Capan2) and one immortalized human pancreatic stellate cell line were cultured by methods known in the art. Briefly, cells were plated to 30% confluence and then perflubron/Egg Yolk Phospholipid emulsion (5.8 mg Perflubron/mL) was added to culture wells in triplicate at dilutions of 1:10, 1:20, 1:40, 1:80, 1:160, 1:320, 1:640, and 1:1280. Following administration of perflubron, samples were either maintained in normoxia conditions (i.e. room air) or hypoxia conditions (i.e. 1% O₂). The metabolic activity was assayed using Almar Blue staining. The fluorocarbon plus carbon dioxide treatment reduced the metabolic activity of immortalized human pancreatic stellate cells as well as pancreatic cancer cells. These results show that fluorocarbon, alone, inhibits cancer cell metabolic activity. Further, these results show that fluorocarbon in combination with gas has greater efficacy at inhibiting cancer cell metabolic activity specifically, in human pancreatic stellate and Pan02 cancer cells greater efficacy of inhibition including metabolic activity was shown in hypoxia, while in Capan2 cancer cells more inhibition was shown in normoxia.

Example 2. Cancer Therapy

A subject with a cancerous mass will undergo a pre-treatment CT/PET scan with fluorodeoxyglucose (FDG) and fluoromisonidazole (FMISO), a tumor hypoxia agent, to establish a baseline. This scan will also identify the volume and location of the hypoxic areas of the cancer mass. Next, at least one needle catheter will be inserted into the tumor and intratumoral pressure will be obtained. If a high intratumoral pressure is observed, a slow instillation of collagenase over 10 minutes may be considered to reduce the pressure (e.g. 30-40%). At this time, intravenous administration of a perfluorocarbon emulsion, chemotherapeutics, radiation agents, or a combination thereof, could be performed to utilize tumor vessels. Since the tumor pressure is lowered by the collagenase, this may enable a higher percent of drug delivery into the tumor.

Once a maximal amount of the intravenous medicine is in the tumor (e.g. ˜4 hours), a slow injection with or without a convection pump of the perfluorocarbon emulsion alone or in combination with additional cancer therapeutics will be injected into the tumor up to a tumor volume amount. Other cancer therapeutics may include chemotherapeutics, radiation (i.e. Rhenium 186), metabolic inhibitors (i.e. 2-Deoxy D Glucose (2DG) and glutaminatic drugs), and combinations thereof. Since the perfluorocarbon emulsion may be visualized in real time by ultrasound, the activity of the injection collapsing the tumor vasculature trapping the perfluorocarbon and chemotherapeutic agents can be monitored. Following the injection of perfluorocarbon, 100% oxygen will be administered intratumorally. The oxygen will be used to enhance chemotherapeutic agents or radiation agents that require oxygen to be effective over the next 2 hours. External beam radiation could also be used at this point. A PET scan or Near Infrared Imaging scan two hours later will be done to examine the hypoxia status. Then, 100% CO₂ gas will be added for 2 hours at a rate up to tumor volume per minute. A capnograph every 10 minutes will be used to determine the subject's CO₂ levels. An ABG every 30 minutes will be performed to follow CO₂ until the 2-hour CO₂ gas treatment is complete. A CT/PET scan with FDG will be done within 30 minutes after CO₂ administration is complete and then again at 4 weeks post-treatment.

Example 3. Metastatic Carcinoma with Ascites

A patient with metastatic colon cancer exhibiting peritoneal studding and greater than 1 liter of ascites fluid will be treated using the following protocol. Before treatment, a pre-treatment PET/CT FMISO, FDG and MM including F-19 will be performed to ascertain the status of the cancer. Laparoscopic insertion of a scope will be used to remove the bulk of the ascites and concurrently a collagenase will be injected intravenously to reduce intratumoral pressure. A 60% perflubron emulsion mixed with the maximum soluble and tolerated amount of 2DG, and possibly collagenase, may be instilled to cover/submerge all of the peritoneal surface metastasis. The combination emulsion is then allowed to mix with the CO₂ gas of the laparoscopic procedure. The abdomen will be supported with the combination for 2 hours. Approximately 4-24 hours post-op, the gas will be changed to O₂ by having the patient breathe supplemental or hyperbaric O₂. Chemotherapeutics and localized radiation may be administered at this time independently or in combination. Following the ascribed procedure, a PET/CT with FMISO and FDG Mill with F-19 will be performed to ascertain the status of the cancer post-treatment.

Example 4. Pancreatic Cancer

A patient with a pancreatic mass in the head of the pancreas, which is surgically unresectable or where the patient chooses a less invasive treatment, will be treated with the following protocol. A pre-operative CT/PET scan using FDG and FMISO, as well as an MRI including a F-19 MRI and MRA of the biliary system will be conducted to assess the status of the cancer. Chemotherapy may be administered to the patient. For example, Gemcitabine with or without perflubron emulsion may be administered intravenously or intra-arterially. Open surgery, laparoscopic surgery, or endoscopy using ultrasound will be used to visualize the pancreas and slowly instill perflubron emulsion with 2DG and L-asparaginase to block the glucose and glutamine uptake by cancer cells. The combination will be instilled to completely fill the mass via convection and controlling reflux and overflow to the extent possible. Next, oxygen will be instilled for 20 minutes in combination with external beam radiation or radiation implantation (e.g. seeds or agent such as Rhenium 186 bonded to perflubron emulsion and administered). Chemotherapeutics and biologics such as antibody-based therapies may be directly instilled along with the combination. Following the oxygen administration, the gas will be switched to CO₂ for the definitive kill dose for 10 to 120 minutes. Needle gas ports may be placed to monitor CO₂ saturation. Monitoring of CO₂ saturation ensures that normal tissue is not contaminated or minimally exposed to increase CO₂ saturation. Devices such as near infrared imaging or other novel instruments may be used to track CO₂ position. A follow-up PET/CT and MRI will be performed to analyze metabolic and structural changes.

Example 5. Head and Neck Cancer

A clinically negative Head and Neck cancer patient generally has a 20-40% reoccurrence rate making selective or modified radical neck dissection desirable. In contrast, 60-80% of patients undergo unnecessary morbidity with this procedure (Peng et al., World J Surg Oncol. 2015; 13: 278. Published online 2015 Sep. 17). The use of perflubron emulsion (PFCE) in combination with IRDye® 700DX (LI-COR, Lincoln, Nebr.) coupled to a ligand (e.g., RGD (arginine-glycine-aspartic acid), monoclonal antibody [such as e.g., pantitumumab], and the like) injected intravenously or topically applied then injected peritumorally preoperatively enables lymph node mapping by various means and subsequent photodynamic therapy (PDT) prior to surgery. The mapping means include, e.g., computed tomography (CT), magnetic resonance imaging (MM; conventional and F19), Raman spectroscopy and probe confocal laser endomicroscopy (pCLE). The use of photodynamic therapy (PDT) on positive tumors, lymph channels (LC) and sentinel lymph nodes (SLN) sites prior to surgical manipulation or removal will mitigate the release of viable cancer cells during surgery. The PFCE-dye-target combination will also aid the evaluation of ex vivo tissue after surgical removal.

In some situations, preoperative near infrared imaging is limited due to location and depth. Indocyanine green (ICG) or a nonspecific dye (e.g., IRDye® 800CW) coupled to albumin is used intraoperatively to map the LC and SLN that do not necessarily contain tumor. A multispectral imaging device that detects 700 nm and 800 nm (and other wavelengths) of light are used. Initial studies utilize radioactive technetium and methylene blue, which are the current standard of care (SOC).

For example, a 65-year-old male patient is referred who has a clinically negative exam except for a tongue mass. The patient may have buccal, floor of mouth or other head and neck masses. A PET/CT and MRI and LN biopsy and selective lymph node dissection is planned. The patient takes an oral solution (or intravenous injection) or has his lesion sprayed or painted with perfluorooctyl bromide (PFOB) or PFCE combined with IRDye® 700DX RGD, PFOB/PFCE-nintedanib-IRDye® 700DX, HAL, verteporfin, or the like. After rinsing (or overnight in case of per os route of administration), the mass is scanned by pCLE.

If the image confirms cancer suspicions, then the patient is informed, and the tumor site is peritumorally injected with the PFOB/PFCE combination at Day 1. After local anesthesia, up to four (4) peritumoral sites after local anesthesia on Day 1 in clinic with 0.5-4 ml PFCE-IRDye® 700DX-RGD (or the like). In some cases, the practitioner may opt for brief PDT and biopsy for histology at the first referred clinic visit. In those cases, the referring provider has already transmitted a photo to the Head and Neck surgeon and the patient had been advised to spray topically one to three days prior to PDT, which is administered at the time of appointment.

On Day 3 a non-contrast CT and MRI Head and Neck (MRI could include F₁₉) and transcutaneous near infrared imaging (NIR) or MSOT is performed. The patient then has topical application of PDT agent then undergoes PDT of the tumor and identified LC and SLN followed by biopsy if not already completed. The patient is then scheduled for surgery and all positive sites subjected to PDT prior to removal. A follow up baseline MRI at about 2 weeks is expected to reveal PFCE fading and repeat NIR/MSOT imaging to be negative.

This protocol is expected to eliminate the need to pre-operatively inject the patient peritumorally with technetium (Tc) and methylene blue. ICG or similar nonspecific NIR (e.g., IRDye® 800CW-albumin) would be used to map non-specific LC and SLN. A 700 nm and 800 nm laser (or other near IR or IR light-source matched to verteporfin, HAL, or the like) with sufficient power is used to treat the primary tumor, all LC and SLN and/or nearby negative nodes with PDT prior to surgical manipulation to avoid spread of tumor. The PDT is not expected to perturb the pCLE or surgical pathologist's evaluation.

Example 6. Routine Colonoscopy

The difficulty in identifying and treating colon cancer is expected to be improved with new image guided and treatment for minimally invasive procedures such as colonoscopy, bronchoscopy, cystoscopy or similar limited invasive applications. A patient with a mass or suspected mass is administered a PFOB or PFCE combined with a nonspecific or a specific fluorescent dye orally, instilled, intravenously, aerosolized or the like. Nonspecific agents such as indocyanine green or 5-aminoallyl, or more tumor-specific agents such as verteporfin, or specific targeted therapies such as monoclonal antibodies and small molecule inhibitors (e.g., nintedanib, afatinib and the like) may be used. The patient then undergoes an image guided procedure within about one to three days followed by photodynamic therapy prior to biopsy and evaluation for sentinel lymph node and lymphatic channels.

The combined anti-fibroblast, anti-macrophage and/or anti-inflammatory activity plus the improved vehicle, added oxygenation potential and imaging with Raman spectroscopy or stimulated Raman spectroscopy, pCLE, NIR, MRI (preferably F-19) and CT benefits the work up, treatment and follow-up. This process also encompasses theragnostic procedures (diagnostic+therapeutic) that includes pre- and post-biopsy photodynamic therapy (PDT).

In one example, a 50-year-old male patient who needs a routine colonoscopy undergoes a colonoscopy preparation. Following the slowing of loose stools approximately six hours later, the patient drinks about 100 ml of a PFOB- or PFCE-IRDye® 700DX-nintedanib labeled product. The next day at colonoscopy, the patient is started on 100% O₂ to “load” the PFOB/PFCE before CO₂ insufflation. A fluorescent and Raman detector fixed to the scope or placed down the working channel is used to identify cancerous lesions. Since 5% of nintedanib is absorbed, 95% is available intraluminal. The PFOB/PFCE enhances the uptake of the nintedanib by the tumor relative to nintedanib alone. Afatinib, regorafenib or other agent and or local spray maybe substituted for the nintedanib. Near infrared imaging of the lumen and nearby lymphatics accessible during the colonoscopy is also performed.

Prior to biopsy, the patient undergoes PDT followed by biopsy and then a peritumoral injection of the same product. Once the biopsy confirms invasive cancer, a CT/MRI Abdomen/Pelvis is completed to view the lymphatics for use during a near term laparoscopic procedure. Prior to or at time of laparoscopy, the patient is administered concurrent ICG and/or Tc to have image non-specific areas. If a multispectral detector is not available, then treatment of all lymphatic channels and lymph nodes is performed prior to biopsy or surgical manipulation. A reduction in tumor re-occurrence in the lymph node basin and lymphatic channels harboring in transit tumor will be reduced.

In another example, a 70 kg 55-year-old male presents for routine screening colonoscopy. He drinks 200 ml of neat perflubron after he completes his colon preparation. The next day the colonoscope is inserted and a Raman spectral unit is used to navigate and scan the colon surface until the light encounters 3 concentrated areas of carbon-fluorine bond (C-F) signal. The Raman spectra PFOB is identified is then that scope is removed and a probe confocal endomicroscopy (pCLE) probe is inserted. The identified area is subjected to pCLE to visualize early cancer lesions. The early cancer lesions are treated with photo dynamic therapy (PDT), removed and sent for pathological confirmation.

This procedure allows a more sensitive method of screening using Raman spectroscopy immediately followed by diagnosis (pCLE) and subsequent treatment (PDT) all within the same procedure thereby reducing cost, complications and time. This protocol can be carried out in multiple other endoscopic or similar procedures such as screening for oral cancer, esophagus, gastric, colon, breast, pancreatic, lung, bladder and peritoneum among others. Current commercial units such as the Verisante AURA™ or those built by companies such as B&W Tek may be used in the practice of the invention, including numerous other and as yet undiscovered detectors using a Raman signature of perfluorocarbons.

Example 7. Patient with a Lung Mass

In one example, a 60-year-old smoker with an 8 mm lung mass in the right upper lobe undergoes CT/PET with a maximum standardized uptake value (SUV) of 2.1. The patient is recommended for a follow-up CT scan in 4-6 months but instead is given perflubron/verteporfin by intravenous injection or aerosol and then CT/MRI done to locate perflubron and then bronchoscopy performed using fluorescence PDD at e.g., 400-499 nm for verteporfin then PDT 689 using modified navigational equipment (no current devices detect fluorescence) (e.g., SUPERDIMENSION™ [superDimension, Inc., Minneapolis, Minn.], SPIN Thoracic [Veran Medical Technologies, Inc., St. Louis, Mo.], or LUNGPOINT® VBN [Broncus Medical, Inc., San Jose, Calif.]). A laser is used to detect and aid guidance to the lesion and a subsequently deliver light for PDT prior to biopsy. Lymph nodes and channels are inspected where possible, and PDT is performed. A post PDT peritumoral injection is performed. The patient can then have biopsy by navigational bronchoscopy or video-assisted thoracoscopic surgery (VATS) after the biopsy is evaluated and fluorescence confirmed ex vivo. The patient PDT is repeated before and after resection in all masses, lymph channels, and lymph nodes. Treatment before biopsy and post biopsy reduces risk of spreading tumor and helps sterilize the post biopsy site. Raman spectroscopy, OCT and other imaging technologies may also be utilized in this method.

Example 8. Patient with a Bladder Mass

In one example, a 70-year-old smoker with hematuria (high pre-test possibility for cancer) is seen on Day 1 and the clinic cystoscopy is suspicious for cancer. PFCE-verteporfin is administered intravenously or intravesicularly to the patient. On Day 3 an MRI/CT abdomen pelvis is performed. On Day 4 a laparoscopy and cystoscopy using NIR is performed. ICG or IRDye® 800CW can be used to navigate the lymphatics using an 800 nm detector during laparoscopy.

Example 9. Melanoma and Non-Melanoma Skin Conditions

In one example, a 42-year-old with a suspicious black spreading lesion is referred for evaluation. A PFCE-IRDye® 700DX-RGD spray or topical is applied to the lesion, rinsed and examined by pCLE. If direct pCLE evaluation suggests cancer, then the patient is informed and peritumorally injected with the PFCE-IRDye® 700DX-RGD product. The patient follows up two to four days later for (1) an MRI F-19, (2) CT/PET RGD (or nintedanib or the like) and NIR, (3) MSOT, (4) PDT and then (5) surgical resection of all positive areas after PDT. Non-specific ICG or IRDye® 800CW is used to map the tissue in real time. Raman spectroscopy may be used to observe the C-F bonds in the tumor area first.

Under another treatment regimen for melanoma or non-melanoma skin conditions, a verteporfin-perflubron composition optionally containing IRDye 800 for deeper PDT penetration is sprayed, brushed, or other topically applied means to the lesion, followed by PDT. This treatment regimen can be repeated regularly over time until the lesion is effectively eliminated.

Example 10. Breast Mass

In one example, a suspicious lesion is seen in a 50-year-old female during a routine mammogram. The patient is peritumorally or intravenously administered PFCE/PFOB-IRDye® 700DX-RGD prior to being subject to ultrasound guided breast biopsy. A 19 G instrument enabling a pCLE catheter to be passed to the edge of the mass is used. If the mass is observed to be cancer-positive, then the mass is treated with PDT, followed by peritumoral injection with the PFCE/PFOB-IRDye® 700DX-RGD that was previously administered by peritumor or intravenous injection, followed by tumor-only PDT and biopsy. If the biopsy is positive, the patient is subjected to MRI F-19 and CT/PET RGD, and MSOT. The patient is then subjected to PDT of mass, LC and SLN prior to resection of the mass. Raman spectroscopy may be used to observe the C-F bonds in the tumor area first.

Example 11. Ovarian Cancer

In one example, a 55-year-old female is referred for ascites. A CT abdomen and pelvis scan reveals “caking” over the omentum. Interventional Radiology is requested to remove fluid for diagnostic and therapeutic purposes. After obtaining a large volume of ascites fluid, the fluid is mixed ex vivo with PFCE/PFOB-IRDye® 700DX-RGD and imaged. If the 700 nm signal is positive in the ascites, the patient is injected with 200 ml of the same PFCE/PFOB-IRDye® 700DX-RGD composition and subjected to CT/PET RGD or nintedanib/afatinib, MM and NIR/MSOT. Two to four days later, the abdominal/pelvic cavity is subjected to PDT and surgical debulking is performed. A laser diode left in place for subsequent PDT.

Example 12. Additional Cancers

A patient with prostate cancer suspicion is administered by way of the urethra a PFCE/PFOB-IRDye® 700DX-target moiety composition. IRDye 800 may also be used here in place of the IRDye 700. The prostate is subjected to PDT prior to prostate biopsy to prevent inadvertent release of potential viable tumor cells. The target moiety is a prostate cancer antigen-binding protein, an RGD peptide, a TKI such as nintedanib or afatinib, or the like.

A patient with glioblastoma suspicion is intravenously administered a PFCE/PFOB-IRDye® 700DX-target moiety composition. If the prospective lesion is fluorescent positive, the lesion is peritumorally injected with the same composition and subjected to PDT prior to biopsy. Follow up MRI, CT/PET RGD and PDT is performed prior to tissue resection. The target moiety is a glioblastoma antigen-binding protein, an RGD peptide, a TKI such as nintedanib or afatinib, or the like.

A patient with pancreatic cancer suspicion is intravenously administered a PFCE/PFOB-IRDye® 700DX-target moiety composition. If the prospective lesion is fluorescent positive, the lesion is peritumorally injected with the same composition and subjected to PDT prior to pancreatic biopsy. Follow up MRI, CT/PET RGD and PDT is performed prior to tissue resection. The target moiety is a pancreatic cancer antigen-binding protein, an RGD peptide, a TKI such as nintedanib or afatinib, or the like. for pancreatic cancer iv or via endoscopic ultrasound known as EUS.

In another pancreatic cancer regimen, a verteporfin-perflubron emulsion composition is injected locally into and around the pancreatic cancer, followed by PDT (IR, gamma, or other deep penetrating radiation may be used). Alternatively, the verteporfin-perflubron emulsion composition is administered intravenously, followed by PDT as described above.

Example 13. Barrett's Esophagus and other Esophageal Indications

In preparation of a patient in need of upper gastrointestinal endoscopy (EGD) for Barrett's esophagus or other upper GI dysplasia, hyperplasia or pre-cancer condition, the patient drinks Perflubron (e.g., 0.5-9 ml/kg) 0.25-24 hours prior to procedure or instills the perfluorooctyl bromide (a.k.a. perflubron) (PFOB) or perflubron emulsion (PFCE) at time of EGD. The PFOB/PFCE is applied over the top of the mucosal surface in a sufficient amount to reduce mucus. Prior art methods employ N-acetylcysteine (NAC), which may impede subsequent photodynamic therapy (PDT). Here, we use of PFOB/PFCE enhances PDT. PFOB/PFCE also enables the use of Raman spectroscopy and similar techniques for visualizing fibroblasts and stroma.

While not wishing to be bound by theory, PFOB/PFCE, which is denser than water and has a significant elevated spreading coefficient, can distribute below the mucus layer. The PFOB smooths out the epithelial surface thereby reducing the scatter from the upcoming laser.

Example 14. Tumor to background ratio

Tumor-bearing mice were injected via tail vein with 200 μg of cetuximab-IRDye®-800CW (1) with 30% perflubron as an emulsion (PFCE), or (2) without PFCE, in a total volume of 200 μL. The mice were then subjected to in vivo imaging at day 3 post-injection using a Pearl® Trilogy Small Animal imaging System (LI-COR Biosciences, Lincoln, Nebr.). The tumor to background ratio (TBR) for each tumor was calculated. The results are depicted in Table 1. The inclusion of 30% PFCE resulted in a 34% (p=0.05) increase in TBR.

TABLE 1 In Vivo TBR Drug combination TBR at 3 days post-injection Cetuximab-IR800 (w/out PFCE) 3.6 (sd = 0.4) Cetuximab-IR800 + PFCE 4.8 (sd = 0.9)

Tumors (NSCLC) and other tissues were then removed from the mice and the tumors and tissues were subjected to ex vivo Pearl® imaging. The tumor to liver ratio for each tumor was calculated. The results are depicted in Table 2. The inclusion of 30% PFCE resulted in an 85% (p=0.01) increase in tumor to liver ratio.

TABLE 2 Ex Vivo Tumor to Liver Ratio Drug combination TBR at 3 days post-injection Cetuximab-IR800 (w/out PFCE) 2.5 (sd = 0.6) Cetuximab-IR800 + PFCE 4.6 (sd = 0.6)

In another experiment, 10 mice harboring human tumors were injected in the tail vein with 200 μg cetuximab-IRDye®-800CW combined with perflubron. The mice were subjected to in vivo Pearl® imaging at day 4 and at day 7. The tumor to background ratio (TBR) for each tumor was calculated. The results are depicted in Table 3. The inclusion of 30% PFCE resulted in a 34% (p=0.05) increase in TBR.

TABLE 3 In Vivo TBR Drug combination Time Post-Injection TBR Cetuximab-IR800 (w/out PFCE) 4 2.5 7 3.2 Cetuximab-IR800 + PFCE 4 5.5

Example 15. Tumor labeling—stromal cells and cancer cells

Tumors and other tissues were removed from tumor bearing mice 4 days after tail vein injection with PFCE+cetuximab-IR800 treated (200 μL at 200 μg cetuximab-IR800). The dissected tissues were lymph nodes 1-4 (LN), tumor metastasis, tumor, kidneys, spleen, liver, lung, heart, brain, muscle, and skin. The excised tissues from those animals treated with PFCE+cetuximab-IR800 were subjected to ex vivo Pearl® imaging and the fluorescence intensities at 700 nm and 800 nm were determined. FIG. 1 depicts the mean fluorescence intensity for each tissue at 700 nm, which is attributed to the localization of the PFCE. Here, the tumor showed an approximately 4-fold greater fluorescence intensity at 700 nm than liver tissue. FIG. 2 depicts the mean fluorescence intensity for each tissue at 800 nm, which is attributed to the localization of the cetuximab-IR800 NIR-C. Here, the tumor showed an approximately 4-fold greater fluorescence intensity at 800 nm than liver tissue.

Example 16. Bladder Cancer Treatment with Photosensitizer

A patient with multiple non-muscle invasive bladder cancers (Tis, Ta, and/or T1 transitional carcinoma) who had transurethral bladder resection and then BCG instillation therapy due to recurrence is presented with the options of repeat BCG (only 20% effective), chemotherapy, cystectomy, or photodynamic therapy (PDT). The patient elects PDT. After transurethral resection of bladder tumor (TURBT) or cystoscopy and no biopsy, 50 milliliters of neat perflubron is instilled into the bladder and held for 1 hour. The patient then urinates or the Foley catheter is removed.

24 to 72 hours later, the tumor stroma is loaded with perflubron and a CT and MRI is optionally used for tumor mapping. Then after mapping the same day, a photosensitizer such as e.g., Hexaminolevulinate (HAL) or talaporfin (TALO) is instilled and held in the bladder for about 1 hour. The uptake of HAL or TAL into cancer cells is increased since the stroma is saturated with perflubron increasing exposure of HAL or TAL to cancer and potentially shortening the HAL/TAL dwell time.

The patient is then placed on supplemental O₂ and the tumor is inspected under white light, followed by applying Karl Storz D-light, followed with inserting a laser fiber through the working channel and applying Karl Storz T-light or similar (with or without a cap) until the occurrence of photobleaching of bladder tumor neck occurs. Photobleaching is expected to occur within 30 minutes or less. When a cap is used, the cap is filled with perflubron and a partial or complete seal is formed around the tumor, and local PDT is performed. After PDT, the perflubron remains in situ for about 1 hour before release through urethra.

HAL or TAL is administered intravascularly, and the cancer is identified using FDA approved photodynamic diagnosis with Karl Storz PD D-light. Next, the bladder is emptied and 50-200 milliliters of oxygen saturated perflubron is instilled and the PDT laser is activated. The oxygen saturated perflubron and optional supplemental O₂ dwells for another hour before removal.

Example 17. Recurrent Esophageal cancer within muscularis propria

The patient has developed recurrent esophageal cancer 1 year after completing chemoradiation. The patient declined surgery and repeat chemoradiation but accepted PDT with Talaporfin (Laserphyrin).

The patient is given 30 milliliters of neat perflubron per os for esophagogastroduodenoscopy (EGD) (higher doses e.g. 200 milliliters and multiple doses are required for other procedures such as colonoscopy) and Talaporfin intravenously 4-48 hours before surgery. EGD is then performed with a cap. The pre-PDT administered perflubron assists in removing mucous from the lesion and saturating the local tumor stroma. An alternative treatment regimen provides for the intravenous or topical administration of perflubron emulsion plus talaporfin.

Photodynamic diagnosis (PDD) is performed to identify the boundaries of the lesion. Then either (i) a spray catheter delivers oxygenated perflubron to the lesion, followed by placing a cap over the lesion and performing PDT, or (ii) if the general boundaries of the lesion are determined and the lesion can be covered or brought into the cap, then the cap is filled with oxygenated perflubron. In some instances, a snare holds the lesion and the cap fills with oxygenated perflubron. Care is taken to avoid cutting off the blood supply and reducing local oxygen to the lesion. The lesion is released or resected after PDT.

In some cases, a submucosal injection of either saline or oxygenated neat or emulsified perflubron is used to prepare the site for snaring. A combination snare-laser fiber (i.e., a laser is built into the snare) is used to perform PDT on the base of the tumor and submucosal areas (if resected or not). This contemplated step is expected to prevent metastatic cancer cells from spreading during snaring or biopsy manipulation. The cap avoids the exposure of the CO2 insufflation and the perflubron-charged O₂ reservoir enables extended free radical formation. (The perflubron not only serves as the reservoir of O₂, but also provides anti-stromal activity to boost tumor killing.) An optional post-operative dose of O₂-charged perflubron is administered, and the patient is placed on high oxygen concentration during PDT. A repeat EGD can be done at 24 hours and repeat PDT as needed.

Example 18. Endoscopy procedures with distal cap

Bronchoscopy, rhinoscopy, laryngoscopy, skin and other scopes and procedures use the same principle described in the previous examples to deliver a photosensitizer and to place a subcutaneous “moat” of neat or emulsified perflubron emulsion around the tumor site immediately prior to PDT. During PDT, a cap or pad infused with perflubron is placed in the immediate area to guard against CO₂ or nitrogen infiltration into the PDT “killing zone.” Oxygenated perflubron is administered for the duration of PDT, the duration of which is expected to be shortened given the increased oxygen radical formation possible with the oxygen-saturated perflubron. The emulsion is expected to enhance uptake into the lymphatics and to also increase lifetime of free radicals.

Example 19. Colon Cancer Cell Killing

Materials: Perfluorocarbon emulsion (PFCE) was produced by combining 60% perflubron with phosphate buffered saline to a final concentration of 10%, 20%, and 30% and mixing on a shaker for about four hours at room temperature. HCT116 colon cancer cells, which are EGFR+, were plated at 0.5×10{circumflex over ( )}5 cells/well in a 24-well plate and incubated overnight in DMEM+10% FBS. Cetuximab-IRDye800 (2 mg/ml stock, lot UABVPF150115) was diluted in DMEM+10% FBS to a concentration of 10 μg/ml and added at 0.5 ml to each well and incubated overnight.

Cells were laser irradiated at 792 nm (infrared radiation [IRR]) using a SPY Elite fluorescence imaging system (Novadaq, Stryker, Kalamazoo, Mich.) with an energy of 53 J/cm{circumflex over ( )}2 for 150 seconds (0.357 W/cm{circumflex over ( )}2) at a distance of 4.5 cm. Cells were monitored microscopically at 100-200X with an EVOS Cell Imaging System (Thermo-Fisher, Waltham, Mass.). 24 hours after irradiation, the cells were trypsinized and viability was assessed by trypan blue exclusion. The results (N=3) are shown in FIG. 3.

Treatment of cells with 10% PFCE with IRR, 20% PFCE with IRR, 30% PFCE with IRR, or 10% PFCE with IRR plus Cetuximab-linked IRDye 800 showed significant cell killing relative to controls. Treatment of cells with 20% PFCE with IRR plus Cetuximab-linked IRDye 800 or 30% PFCE with IRR plus Cetuximab-linked IRDye 800 showed significantly more cell killed relative to the respective treatments without the Cetuximab-linked IRDye 800 present, i.e., PFCE in combination with Cet-IR800 and IRR-792 nm produced approximately 50% cell death at 20% and 30% PFCE.

It was generally observed that PFCE fluorescence is detected at near infrared 700 nm, and the signal intensity is dose dependent. At 10% perflubron, the 700 nm mean fluorescence index was observed at about 6×10{circumflex over ( )}′4 arbitrary units, 20% perflubron at about 13×10{circumflex over ( )}\4 arbitrary units, and 30% perflubron at about 30×10{circumflex over ( )}′4 arbitrary units. It was also observed that PFCE potentiates Cetuximab-IRDye800 as a PDT agent with 792 nm infrared radiation by producing significant cancer cell killing.

The invention illustratively disclosed herein suitably may be practiced in the absence of any element, which is not specifically disclosed herein. It is apparent to those skilled in the art, however, that many changes, variations, modifications, other uses, and applications to the method are possible, and also changes, variations, modifications, other uses, and applications which do not depart from the spirit and scope of the invention are deemed to be covered by the invention, which is limited only by the claims which follow. 

1. A composition comprising molecular oxygen (O₂), perflubron, and a photosensitizer, wherein the composition is free of carbon dioxide. 2.-3. (canceled)
 4. The composition of claim 1, wherein said photosensitizer is talaporfin.
 5. The composition of claim 1, wherein said photosensitizer is hexaminolevulinate.
 6. The composition of claim 1, wherein said photosensitizer is Photofrin.
 7. The composition of claim 1, wherein said photosensitizer is a near infrared dye.
 8. The composition of claim 1, wherein said photosensitizer is verteporfin.
 9. (canceled)
 10. A system comprising molecular oxygen (O₂), perflubron, a photosensitizer, and a cap, wherein the system does not comprise carbon dioxide. 11.-12. (canceled)
 13. The system of claim 10, wherein said photosensitizer is talaporfin.
 14. The system of claim 10, wherein said photosensitizer is hexaminolevulinate.
 15. The system of claim 10, wherein said photosensitizer is Photofrin.
 16. The system of claim 10, wherein said photosensitizer is a near infrared dye.
 17. The system of claim 10, wherein said photosensitizer is verteporfin.
 18. (canceled)
 19. The system of claim 10, wherein said cap is positioned at the distal end of an endoscope and the distal end of the cap is open.
 20. A method for treating a tumor or lesion comprising a. administering to a patient in need thereof a photosensitizer, selected from the group consisting of nintedanib, photofrin, talaporfin, hexaminolevulinate, and verteporfin; b. administering to said patient oxygenated perflubron; and c. delivering light to the tumor to effect the generation of reactive oxygen species.
 21. The method of claim 20, wherein said photosensitizer is administered intravenously.
 22. (canceled)
 23. The method of claim 20, wherein said oxygenated perflubron is administered topically.
 24. The method of claim 20, wherein said photosensitizer is administered topically.
 25. (canceled)
 26. The method of claim 20, wherein said photosensitizer is administered prior to the administration of said oxygenated perflubron.
 27. (canceled)
 28. The method of claim 24, wherein said tumor or lesion is a skin tumor or skin lesion.
 29. The method of claim 20, wherein said photosensitizer and said oxygenated perflubron are combined and administered to said patient as a combination.
 30. The method of claim 20, wherein said photosensitizer and oxygenated perfluorocarbon are administered to the tumor through an endoscope and wherein the distal end of said endoscope is fixed to a cap, said cap is positioned over said tumor, and said photosensitizer and oxygenated perfluorocarbon are delivered into said cap over said tumor.
 31. (canceled)
 32. The method of claim 30, wherein said light is delivered through said endoscope to said tumor, and wherein said light comprises a wavelength that excites said photosensitizer. 33.-53. (canceled) 